THE  1  IBRARY 


THE  UNIVERSITY 


OF  CALIFORNIA 


LOS  ANGELES 


Sixth 


/ 

International 


Dermatological  Congress 

Held  at  the 

New  York  Academy  of  Medicine 

15-17  West  43d  Street 
September  9th  to  14th,  1907 


Official  Transactions 


Edited  by 

John  A.   Fordyce,  M.D, 

Secretary-General 
VOLUME    I. 


ttbe  Knickerbocker  press 

Hew 

1008 


COPYRIGHT 

BY 

JOHN  A.  FORDYCE 
1908 


Biomedieai 
Library 

W3 


(107 


CONTENTS. 

PACK 

LIST  OF  ILLUSTRATIONS    .......        v 

LAWS  OF  CONGRESS  ........         i 

LIST  OF  OFFICERS     ........         5 

LIST  OF  THEMES  SELECTED  FOR  DISCUSSION          ...         8 
LIST  OF  MEMBERS     .  .          ...  9 

LIST  OF  DELEGATES  .          .         .         .         .         .         .14 

PROCEEDINGS  OF  FIRST  DAY       .         .         .         .         .  15 

PROCEEDINGS  OF  SECOND  DAY    .         .         .         ,         .         .156 
PROCEEDINGS  OF  THIRD  DAY      ......     334 

PROCEEDINGS  OF  FOURTH  DAY — MORNING  SESSION       .         .     438 


iii 


ILLUSTRATIONS 

OPP. 
PACE 

PLATES  I-IV. — A.  LASSUEUR.     ........     66 

FIGS,  i  and  2. — Lupus  vulgaris  of  cheek  and  ear  before  and  after 
treatment  with  tuberculin  of  BeYaneck 

FIGS.  3  and  4. — Lupus  vulgaris  of  nose  and  cheeks  before  and  after 
treatment  with  tuberculin  of  BeYaneck 

PLATE  V — M.  B.  HARTZELL.      .          .          .          .          .          .          .          .182 

Histology  of  idiopathic  multiple  hemorrhagic  sarcoma  (Kaposi) 

PLATES  VI-VIII. — M.  L.  HEIDINGSFELD.  .          .          .          .          .          .    196 

FIG.  i. — Multiple  benign  cystic  epithelioma  of  nose 

FIG.  2. — Multiple  benign  cystic  epithelioma  about  orbit 

FIG.  3. — Section  of  tumor  showing  epithelial  strands  and  cysts 

FIG.  4. — Same  as  Fig.  3  more  highly  magnified 

FIG.  5. — Cysts  and  adenoma  of  sebaceous  glands 

FIG.  6. — Transverse  section  of  hair   follicle   giving   off   horn-like 
processes 

PLATES  IX-XII.—H.  Fox 226 

FIG.  i. — Keloid 

FIG.  2. — Lichen  ruber  acutninatus 

FIGS.  3  and  4. — Hereditary  syphilis,  annular  form 

FIGS.  5  and  6. — Acquired  syphilis,  annular  form 

FIG.  7. — Keloid  acne 

FIGS.  8  and  9. — Leucoplakia  buccalis 

FIG.  10. — Multiple  keloid 

FIG.  it. — Leuconychia 

FIG.  12. — Vitiligo 
PLATES  XIII-XIV.— H.  P.  TOWLE .         .258 

FIGS.  1-5. — Lesions  of  gangrasna  cutis  hysterica 

PLATES   XV-XVI. — J.    F.   SCHAMBERG,    N.    GILDERSLEEVE,   AND    H. 

SHOEMAKER.  .........   306 

FIG.  r. — Sycosis  vulgaris  before  treatment 


vi  ILLUSTRATIONS 

OPP. 
PAGE 

FIG.    2. — Same   patient   after  two   injections   of   staphylococcic 
emulsion 

PLATB  XVII. — W.  T.  CORLETT 318 

Erythema  exudativum  multiforme 

PLATES  XVIII-XX. — F.  H.  MONTGOMERY  AND  O.  S.  ORMSBY.     .         .  406 

FIG.  i. — Typical  cutaneous  lesion  of  blastomycosis  with  metastatic 
lesions 

FIG.  2. — Nodules  and  ulcers  of  blastomycosis  on  limbs,  five  weeks 
before  death 

FIG.  3. — Giant  cells  containing  blastomycetes 

FIG.  4. — Blastomycetes  in  various  stages  of  budding 

FIG.  5. — Section  of  liver  showing  miliary  abscesses  with   blasto- 
mycetes 

FIG.  6. — Cultures  of  blastomycetes,  four  weeks  old 

FIG.  7. — Old  cultures  of  blastomycetes  showing  large  round  bodies 
and  short  thick  mycelium  with  spore-like  bodies 

PLATES  XXI-XXIIL— R.  ABBE 470 

FIG.  i. — Epithelioma  of  nose  and  upper  lips  treated  with  radium, 
showing  effects  at  end  of  two  and  five  weeks 

FIG.  2. — Location  of  epitheliomata  treated  by  radium  in  seventy- 
seven  cases 

FIG.  3. — Radio-autographic   estimate   of  the    working    value    of 
radium  specimens 

FIG.  4. — Sarcoma   of   lower   eyelid  ;    condition   at  beginning   of 
treatment  with  radium,  at  end  of  two,  four,  and  eight  weeks 

FIG.  5. — Recurrent  subcutaneous  nodule  degenerating  under  one 
radium  application 

PLATE  XXIV. — H.  LAWRENCE.          .  !      .          .          .          .          .          .   496 

Illustrating  the  X-ray  bath 
PLATES  XXV-XXVIIL— W.  A.  PUSEY 504 

FIGS,  i  and  2. — Epithelioma  of  lower  lip  and  lower  eyelid  before 
and  after  treatment  with  X-rays 

FIGS.  3  and  4. — Epithelioma  of  lower  lip  before  and  after  treat- 
ment with  X-rays 

FIGS.  5  and  6. — Epithelioma  of  cheek  before  and  after  treatment 
with  X-rays 

FIGS.  7  and  8. — Epithelioma  of  temple  before  and  after  treatment 
with  X-rays 

PLATES  XXIX-XXXIV.— CH.  W.  STILES 562 

FIGS.  1-4. — Acne-like  condition  and  enlarged  breasts  due  to   in- 
fection with  Sparganum  proliferum 


ILLUSTRATIONS  vii 

OPP. 
PAGE 

FIG.  5. — Sparganum  proliferum  in  part  in  a  cyst 
FIG.  6. — Sparganum  proliferum  escaped  from  a  cyst 

FIGS.  7-15. — Nine  specimens  of  Sparganum  proliferum,  showing 
various  forms,  buds,  and  supernumerary  heads 

FIG.   16. — Section  through  a  cyst  with  the  escaped  Sparganum 
proliferum 

FIG.  17. — Section  through  the  reserve  food  particle  of  Sparganum 
proliferum 

FIG.    18. — Section  of  Sparganum  proliferum,   showing  large  ex- 
cretory canal,  smaller  canals,  calcareous  corpuscles,  and  a  pore 

PLATE  XXXV. — O.  J.  MINK  AND  N.  T.  MCLEAN.        .         .         .         .580 

FIGS.  1—4. — Illustrations  of  mutilation  produced  by  gangosa 
PLATE  XXXVI.— G.  C.  SHATTUCK.  .         .         ..'.-".         .598 

FIG.  i. — (a)  Spirochaeta    refringens   showing  transverse    division 
nearly  complete;  (6)  unidentified  spirochaetas 

FIG.  2 . — Spirochaeta  refringens  undergoing  transverse  division 

FIG.  3. — (a)  Forked  end   of  spirochaetas   suggesting   longitudinal 
division;  (6)  spirochaetae  of  Class  B 

FIG.  4. — Twisted  examples  of  Class  B 

FIG.  5. — (a)  Spirochaetae  of  Class  C  which  approaches  Treponema 
pallidum;  (6)  Spirochaeta  refringens 

FIG.  6. — Spirochsetae  of  Class  C  undergoing  division 
PLATES  XXXVII-XLIII. — A.  CASTELLANI.        .          .      :•         ••         •   65° 

FIG.    i. — Primary  lesion  of  frambcesia  on  the  thumb;    general 
eruption  on  the  face 

FIG.  2. — Primary  lesion  of  frambcesia  under  nipple 

FIG.  3. — Showing  how  Ceylon  women  carry  their  children 

FIGS.  4-7. — Frambcesia;  general  eruption 

FIG.  8. — Frambcesia;    palmar  eruption,  showing  peculiar  pitting 

FIG.  9. — Frambcesia;  general  eruption 

FIG.  10. — Frambcesia;  eruption  on  the  soles  of  the  feet 

FIGS,  ii  and  12. — Frambcesia;  tertiary  eruption  on  heels  and  legs 

FIG.  13. — Spirochaete  pertenuis 

FIG.  14. — Experimental  frambcesia.    Initial  lesion  on  the  left  eye- 
brow of  a  monkey  and  general  eruption  on  upper  lip 

PLATES  XLIV-XLVII. —  A.  CASTELLANI.         .         .  ...  664 

FIG.  i. — Patient  affected  with  pityriasis  flava  (face)  and  pityriasis 
nigra  (neck) 

FIG.  2. — Microsporon  tropicum  (Castellani) 


viii  ILLUSTRATIONS 

OPP. 
PACK 

FIGS.  3  and  4. — Microsporon  Mansoni  (Castellani) 

FIG.  5. — Microsporon  Macfadyeni  (Castellani) 

FIG.  6. — Patient  affected  with  pityriasis  flava 

FIG.  7. — Young  culture  of  Microsporon  Mansoni  (Castellani) 
PLATE  XLVIII. — A.  CASTELLANI.  .  ....   666 

FIG.  i. — Forearm  of  patient  affected  with  tinea  intersecta 

FIG.  2. — Fungus  of  tinea  intersecta 
PLATES  XLIX-L. — A.  CASTELLANI.  ......   670 

FIG.  i. — Patient  affected  with  tinea  imbricata 

FIG.  2. — Fungus  of  tinea  imbricata 
PLATE  LI. — M.  VON  NIESSEN.  .......    760 

FIG.  i. — Serpiginous  syphilide  in   a  rabbit  produced  by  bacillus 
of  von  Niessen 

FIG.  2. — Microscopic  preparation  of  syphilis  bacillus  of  von  Niessen 
PLATE  LII. — S.  EHRMANN.        .          .          .          .          .          .          .          .776 

FIG.  i. — Branching  livedo  racemosa  with  tuberose  syphilide 

FIG.  2. — Spirochaeta  pallida  in  large  macular  syphilide 
PLATE  LIII. — S.  POLLITZER.     ,          .          .          .          .          .          .         .   909 

FIGS.  1-4. — Microscopic  sections  of  a  case  of  sarcoid 

The  Secretary-general  wishes  to  thank  the  Journal  of  the  American  Medi- 
cal Association  for  permission  to  use  the  cuts  illustrating  Dr.  Pusey's 
article;  the  Medical  Record  for  those  used  in  connection  with  Dr.  Abbe's 
article;  the  Revue  Pratique  des  Maladies  Cutanees  Syphilitiques  et  V6n£ri- 
ennes  for  the  cuts  accompanying  Dr.  Lassueur's  article;  and  the  Journal  of 
Cutaneous  Diseases  for  the  majority  of  the  other  illustrations. 


LAWS 

THE  SIXTH  INTERNATIONAL  DERMATOLOGICAL  CONGRESS 
will  be  held  September  gth  to  i4th,  1907,  at  the  Academy  of 
Medicine,  17  West  43d  Street,  New  York,  under  the  following 
regulations: 

I.  The  meetings  will  be  open  to  the  public. 

II.  Any  member  of  the  medical  profession  in  good  standing 
may  become  a  member  of  the  Congress  by  registering  with 
the  Secretary-General  at  the  time  of  the  meeting,  or  previously, 
or  with  the  secretaries  of  their  respective  countries.     The  fee 
for  membership  shall  be  five  dollars  G£i,  20  marks,  25  francs), 
payable  to  the  Secretary-General  in  New  York,  or  to  the  foreign 
secretaries. 

III.  Papers  should  be  presented  in  writing  in  the  English, 
French,  German,  Spanish,  or  Italian  languages,  and  may  be 
discussed  in  the  language  most  familiar  to  the  speaker.     Twenty 
minutes  will  be  allowed  each  person  selected  to  present  the 
questions  proposed  by  the  Committee,  and  ten  minutes  to 
readers  of  voluntary  papers.     Five  minutes  will  be  granted 
to  any  member  for  discussion  of  papers.     Members  desiring 
to  present  papers  shall  announce  to  the  Secretary-General 
the  title  before  May  ist,  1907,  and  shall  send  an  abstract  of 
the  same  to  him  before  that  date.     A  full  copy  of  every  paper 
presented  shall  be  given  to  the  Secretary  of  the  Session  im- 
mediately after  it  is  read. 

IV.  Precedence  in  debate  will  be  given  to  members  who 
announce  beforehand  their  desire  to  take  part  in  it.     Papers 
shall  be  presented  in  the  order  as  given  on  the  official  program. 

V.  The  proceedings  of  the  Congress  will  be  published,  and 
each  member  will  be  entitled  to  a  copy. 

VI.  Clinical  Sessions  will,  on  certain  days,  precede  those 
for  the  presentation  of  papers,  at  which  proper  time  shall 
be  allowed  for  the  formal  discussion  of  important  cases.     Time 
will  also  be  allowed  for  the  exhibition  of  drawings,  paintings, 
photographs,  models,  microscopical  demonstrations,  and  ap- 
paratus relating  to  dermatology. 

VOL.  I— I  I 


STATUTEN 

I.  Die  Sitzungen  sind  offentlich. 

II.  Als  Mitglieder  des  Congresses  werden  qualificirte  Aerzte 
zugelassen,  die  sich  bei  dem  General-Sekretar  zur  Zeit  der 
Sitzung  oder  bei   den   Sekretaren   der  betreffenden   Lander 
anmelden.     Der  Mitgliedsbeitrag  betragt  funf  Dollars  (£i,  20 
Marks,  25  Francs),  zahlbar  an  den  General-Sekretar  in  New 
York  oder  den  betreffenden  auslandischen  Sekretar. 

III.  Vortrage  sind  in  englischem,  franzosischem,  italien- 
ischem,  spanischem  oder  deutschem  Manuscript  einzureichen, 
und  kann-  die  Discussion  in  der  Sprache  stattfinden,  die  dem 
Redner  am  gelaufigsten  ist.     Die  Zeit  fur  den  Vortrag  eines 
von  dem  Committee  mit  einem  Referat  betrauten  Mitgliedes 
ist  auf  zwanzig  Minuten,  fur  Einzelvortrage  auf  zehn  Minuten, 
fur  Reden  in  der  Discussion  auf  funf  Minuten  festgesetzt. 
Mitglieder,  die  einen  Vortrag  zu  halten  wiinschen,  haben  das 
Thema  vor  dem  i.  Mai,  1907,  anzumelden  und  einen  Auszug 
des  Vortrages  vor  dem  i.  Mai,  1907,  an  den  General-Sekretar 
einzureichen.     Die    vollstandigen    Manuscripte    aller    Reden 
mussen  nach  beendetem  Vortrag  sofort  dem  Sekretar  der 
Sitzung  eingehandigt  werden. 

IV.  Beider  Discussion  sollen  diejenigen  Mitglieder  den  Vor- 
tritt  haben,  die  den  Wunsch,  sich  an  derselben  zu  beteiligen, 
vorher  angemeldet  haben.     Vortrage  sollen  in  der  im  officiellen 
Programm  angegebenen  Reihenfolge  gehalten  werden. 

V.  Die  Verhandlungen  werden  im  Congress-Bericht  verof- 
fentlicht  und  ist  jedes  Mitglied  zu  einem  Exemplar  desselben 
berechtigt. 

VI.  Klinische  Sitzungen  sollen  an  den  bestimmten  Tagen 
den  Vortragen  vorausgehen,  und  fur  die  Diskussion  wichtiger 
Falle  soil  eine  angemessene  Zeit  festgesetzt  werden.     Auch  soil 
fur  die  Ausstellung  von  Zeichnungen,  Bildern,  Photographien, 
Modellen,  mikroskopischen  Praparaten,  dermatologischen  In- 
strumenten  und  Apparaten  geniigende  Zeit  gewahrt  werden. 


REGLEMENTS 

I.  Les  seances  seront  publiques. 

II.  Tous  les  membres  reguliers  de  la  profession  me"dicale 
peuvent  devenir  membre  du  congres  en  s'inscrivant  chez  le 
secretaire  general  au  moment  des  seances,   ou  auparavant, 
ou  avec  les  secretaires  de  leur  pays.     Le  montant  de  la  cotisa- 
tion  sera  de  Cinq  Dollars  (20  Marks,  25  Francs,  £i),  payable  a 
New  York  au  secretaire  general  ou  aux  secretaires  etrangers. 

III.  Les  manuscrits  devront  etre  ecrits  en  Anglais,  Frangais, 
Allemand,  Espagnol  ou  Italien,  et  pourront  6tre  discut6s  dans 
le  langage  le  plus  familier  a  1'orateur.     On   accordera   vingt 
minutes  a  chaque  personne  choisie  pour  presenter  les  questions 
proposees  par  le  comite  et  dix  minutes  aux  lecteurs  de  manu- 
scrits non  preablement  annonces.     On  accordera  cinq  minutes 
a  chaque  membre  pour  la  discussion  des  manuscrits.     Les 
membres    desirant    presenter    leurs    manuscrits    devront    en 
annoncer  le  titre  avant  le  ier  Mai  1907,  et  devront  en  envoyer 
un  extrait  au  secretaire  general  avant  cette  date.      Une  copie 
exacte  des  manuscrits  pr£sentes  devra  6tre  donnee  au  secre- 
taire de  la  seance  immediatement  apres  lecture  faite. 

IV.  La  precedence  dans  les  debats  sera  accordee  aux 
membres  qui  annonceront  a  Favance  leur  intention  d'y  prendre 
part.     Les  manuscrits  seront  presentes  dans  1'ordre  donne 
par  le  programme  officiel. 

V.  Le  compte  rendu  du  congres  sera  publie  et  chaque 
membre  du  congres  aura  droit  a  un  exemplaire. 

VI.  A  certains  jours  les  sessions  de  cliniques  precederont 
la  presentation  des  manuscrits.    Dans  ces  sessions,  on  accordera 
le  temps  necessaire  pour  la  discussion  formelle  des  cas  im- 
portants.       On    accordera    aussi    le    temps  necessaire   pour 
1'exposition  des  dessins,  peintures,  photographies,  modeles,  pour 
les  demonstrations  microscopiques  et  les  appareils  concernant 
la  dermatologie. 

3 


REGLAMENTO 

I.  Las  sesiones  seran  publicas. 

II.  Cualquier  miembro  de    la  profesi6n  me"dica,  puede 
ser  miembro  de  este  Congreso,  inscribie"ndose  con  el  Secretario 
General  6  con  los  secretaries  de  las  respectivas  naciones,  al 
tiempo  de  la  apertura  del  Congreso  6  anteriormente.     La  cuota 
de  inscripci6n  ser£  de  G£i,  20  marks,  25  francos,  5  pesos  oro.) 
pagaderos  al  Secretario  General  en  New  York,  6  a  los  secretaries 
de  las  naciones  extranjeras. 

III.  Las   comunicaciones   se  presentaran  por  escrito  en 
ingle's,   francos,   alemdn,   espanol,   e"   italiano.      La  discusi6n 
podra  hacerse  en  la  lengua  preferida  por  el  congresista.     El 
tiempo  asignado  para  las  comunicaciones  sobre  temas  elegidos 
por  el  Comite',  serd  de  veinte  minutos,  para  comunicaciones 
voluntarias,  diez  minutos;  y  para  discusiones  cinco  minutos. 
Congresistas  que  deseen  presentar  comunicaciones,  anunciardn 
el  titul  antes  del  primero  de  Mayo,  1907,  y  mandarin  un 
extracto  de  la  comunicaci6n  al  Secretario  General  antes  de 
esta  fecha.     Una  copia  en  extenso  de  toda  comunicaci6n, 
serd  entregada  immediatamente  despue"s  de  ser  leida,  al  secre- 
tario  de  la  sesi6n. 

IV.  Las  comunicaciones  se  leer£n  en  el  6rden  indicado 
en  el  programa  oficial.     Se  dard  precedencia  en  las  discusiones, 
£.  los  congresistas  que  hayan  expresado  previamente  su  deseo 
de  participar  en  la  discusi6n. 

V.  Los  trabajos  del  Congreso  seran  publicados,  y  cada 
congresista  tendrd  derecho  d  recibir  un  tomo. 

VI.  Sesiones  Clinicas,  precederdn  ciertos  dias  £  la  pre- 
sentaci6n  de  las  comunicaciones;  en  6stas  se  asignard  tiempo 
suficiente  para  la  satisfactoria  discusidn  de  casos  importantes. 
Tambi6n  se  asignard,  tiempo  para  la  exhibici6n  de    dibujos, 
laminas,  fotografias,  modelos,  demonstraciones  microscopicas, 
y  aparatos  pertenecientes  d,  la  dermatologia. 


President 

DR.  JAMES  C.  WHITE 
Honorary  Presidents 

PROP.  ERNEST  BESNIER  MR.  JONATHAN  HUTCHINSON 

PROF.  EDMUND  LESSER 


AMERICAN: 


Vice -Presidents 

Dr.  William  A.  Hardaway,  St.  Louis 

Dr.  Edward  L.  Keyes,  New  York 

Dr.  Hermann  G.  Klotz,  New  York 

Dr.  Abner  Post,  Boston 

Dr.  Andrew  R.  Robinson,  New  York 

Dr.  Samuel  Sherwell,  Brooklyn 

Dr.  Robert  W.  Taylor,  New  York 

Dr.  Arthur  Van  Harlingen,  Philadelphia 


FOREIGN: 
Austria-Hungary . 


Belgium. . 
Canada.  . 
Denmark . 


France.. 


Germany.. 


Great  Britain  and  Ireland. 


Prof.  P.  J.  Pick,  Prague 
Prof.  E.  Lang,  Vienna 
Prof.  G.  Riehl,  Vienna 
Dr.  Dubois-Havenith,  Brussels 
Dr.  F.  J.  Shepherd,  Montreal 
Prof.  E.  Ehlers,  Copenhagen 
Dr.  L.  Brocq,  Paris 
Prof.  Albert  Fournier,  Paris 
Prof.  E.  Gaucher,  Paris 
Dr.  H.  Hallopeau,  Paris 
Dr.  W.  Dubreuilh,  Bordeaux 
Prof.  O.  Lassar,  Berlin 
Prof.  J.  Doutrelepont,  Bonn 
Prof.  A.  Neisser,  Breslau 
Dr.  P.  G.  Unna,  Hamburg 
Prof.  J.  Caspary,  Konigsberg 
Dr.  W.  Allan  Jamieson,  Edinburgh 
Sir  T.  McCall  Anderson,  Glasgow 
Dr.  T.  Colcott  Fox,  London 
Mr.  Malcolm  Morris,  London 
Dr.  J.  J.  Pringle,  London 
k  Dr.  H.  Radcliffe-Crocker,  London 


OFFICERS  AND  COMMITTEES 


Prof.  Tommaso  DeAmicis,  Naples 
Prof.  Vittorio  Mibelli,  Parma 
Prof.  Robert  Campana,  Rome 

Norway  ..  j  Dr.  A.  Hansen,  Bergen 

(  Prof.  C.  Boeck,  Christiania 

Portugal Dr.  Zeferino  Falcao,  Lisbon 

j  Prof.  A.  Posp61ow,  Moscow 

(  Prof.  O.  von  Peterson,  St.  Petersburg 

Spain Prof.  J.  E.  Ola  vide,  Madrid 

Sweden Prof.  E.  Welander,  Stockholm 

Switzerland Dr.  J.  Jadassohn,  Berne 

Turkey Prof.  Zambaco  Pasha,  Constantinople 

ORGANIZATION  COMMITTEE 


Russia 


Dr.  Andrew  P.  Biddle,  Detroit 
Dr.  John  T.  Bowen,  Boston 
Dr.  Edward  B.  Bronson,  New  York 
Dr.  L.  Duncan  Bulkley,  New  York 
Dr.  R.  R.  Campbell,  Chicago 
Dr.  William  T.  Corlett,  Cleveland 
Dr.  Isadore  Dyer,  New  Orleans 
Dr.  George  T.  Elliot,  New  York 
Dr.  Martin  F.  Engman ,  St.  Louis 
Dr.  John  A.  Fordyce,  New  York 
Dr.  George  Henry  Fox,  New  York 
Dr.  T.  Caspar  Gilchrist,  Baltimore 


Dr.  Milton  B.  Hartzell,  Philadelphia 
Dr.  James  Nevins  Hyde,  Chicago 
Dr.  George  T.  Jackson,  New  York 
Dr.  S.  Lustgarten,  New  York 
Dr.  D.  W.  Montgomery,  San  Francisco 
Dr.  Prince  A.  Morrow,  New  York 
Dr.  William  A.  Pusey,  Chicago 
Dr.  Francis  J.  Shepherd,  Montreal 
Dr.  H.  W.  Stelwagon,  Philadelphia 
Dr.  Grover  W.  Wende,  Buffalo 
Dr.  James  C.  White,  Boston 
Dr.  James  M.  Winfield,  Brooklyn 


Dr.  William  S.  Gottheil,  New  York       Dr.  Joseph  Zeisler,  Chicago 


COMMITTEES 


FINANCE 


Dr.  James  Nevins  Hyde,  Chairman 

Dr.  Andrew  P.  Biddle  Dr.  Howard  Morrow 

Dr.  Edward  B.  Bronson  Dr.  Francis  J.  Shepherd 

Dr.  George  T.  Jackson  Dr.  Grover  W.  Wende 


INVITATION 


Dr.  Henry  W.  Stelwagon,  Chairman 

Dr.  John  T.  Bowen  Dr.  James  Nevins  Hyde 

Dr.  T.  Caspar  Gilchrist  Dr.  Sigmund  Lustgarten 


TRANSPORTATION 


Dr.  L.  Duncan  Bulkley,  Chairman 

Dr.  Isadore  Dyer  Dr.  Francis  J.  Shepherd 

Dr.  D.  W.  Montgomery  Dr.  Charles  M.  Williams 


COMMITTEES  AND  SECRETARIES 


CLINICS   AND    EXHIBITS 

Dr.  John  A.  Fordyce,  Chairman 

Dr.  Henry  G.  Anthony  Dr.  Frank  H.  Montgomery 

Dr.  John  T.  Bowen  Dr.  Jay  F.  Schamberg 

Dr.  Charles  N.  Davis  Dr.  Samuel  Sherwell 

Dr.  George  T.  Elliot  Dr.  Henry  W.  Stelwagon 
Dr.  George  Henry  Fox 


ACCOMMODATIONS 

Dr.  Edward  B.  Bronson,  Chairman 


Dr.  George  T.  Jackson 


Dr.  Prince  A.  Morrow 


RECEPTION    AND    ENTERTAINMENT 

Dr.  George  Henry  Fox,  Chairman 

Dr.  John  T.  Bowen  Dr.  Sigmund  Lustgarten 

Dr.  George  T.  Elliot  Dr.  William  A.  Pusey 

Dr.  Milton  B.  Hartzell  Dr.  Grover  W.  Wende 

Dr.  George  T.  Jackson  Dr.  James  M.  Winfield 


AMERICAN: 


Secretaries 

Dr.  J.  W.  Lord,  Baltimore 

Dr.  Charles  J.  White,  Boston 

Dr.  Frank  H.  Montgomery,  Chicago 

Dr.  A.  Ravogli,  Cincinnati 

Dr.  James  C.  Johnston,  New  York 

Dr.  Fred.  J.  Leviseur,  New  York 

Dr.  A.  D.  Mewborn,  New  York 

Dr.  Henry  H.  Whitehouse,  New  York 

Dr.  Joseph  Grindon,  St.  Louis 

Dr.  Howard  Morrow,  San  Francisco 

FOREIGN  : 

Argentine,  S.  A Dr.  Baldomero  Sommer,  Buenos  Ayres 

Australia Dr.  A.  W.  Finch  Noyes,  Melbourne 

.  .     „  j  Prof.  E.  Finger,  Vienna 

Austria-Hungary •)_.     ,    .    TT    €     ' 

(  Prof.  A.  Havas,  Budapest 

Belgium Prof.  A.  Bayet,  Brussels 

„         ,  |  Dr.  G.  Gordon  Campbell,  Montreal 

'  <  Dr.  Graham  Chambers,  Toronto 

Central  America Dr.  Emilio  Echeverria,  Limon,  Costa  Rica 

Chili,  S.  A Dr.  Alberto  Valdes-Morel,  Santiago 

Denmark Prof.  E.  Pontoppidan,  Copenhagen 

France Dr.  G.  Thibierge,  Paris 

Germany Dr.  O.  Rosenthal,  Berlin 

Great  Britain  and  Ireland Dr.  Arthur  Whitfield,  London 

Greece Dr.  Sp.  Rosolimos,  Athens 

Holland Prof.  S.  Mendes  DaCosta,  Amsterdam 

Italy Dr.  C.  Ciarrocchi,  Rome 

Japan Prof.  K.  Dohi,  Tokio 

Mexico Dr.  Francisco  Bernaldez,  City  of  Mexico 


8  SECRETARIES  AND  THEMES 

Norway Dr.  R.  Krefting,  Christiania 

Portugal Dr.  Thomaz  de  Mello  Breyner,  Lisbon 

Russia Dr.  A.  Lanz,  Moscow 

Roumania Prof.  Petrini  de  Galatz,  Bucharest 

Spain Dr.  A.  Pardo  Regidor,  Madrid 

Sweden Dr.  Magnus  M  oiler,  Stockholm 

Switzerland Prof.  Oltramare,  Geneva 

Turkey Prof.  Zambaco  Pasha,  Constantinople 

West  Indies Dr.  Henry  Robelin,  Havana 

Treasurer  Secretary-General 

Dr.  GEORGE  T.  JACKSON,  Dr.  JOHN  A.  FORDYCE 

New  York,  N.  Y.  New  York,  N.  Y. 


THEMES  SELECTED  BY  THE  ORGANIZATION 
COMMITTEE: 

I.  The  Etiological  Relationship  of  Organisms  found  in 

the  Skin  in  Exanthemata. 

II.  Tropical  Diseases  of  the  Skin. 

III.  (A]  The  Possibility  of  Immunization  against  Syphilis. 
(J5)  The  Present   Status   of  our  Knowledge  of   the 

Parasitology  of  Syphilis. 


MEMBERS  OF  THE  CONGRESS 


Abbe,  Robert,  New  York 
Abrahams,  A.,  New  York 
Aitken,  J.  F.,  New  York 
Alderson,  Harry  E.,  San  Francisco 
Aldrich,  John,  New  York 
Allworthy,  Samuel  W.,  Belfast 
Anderson,  T.  McCall,  Glasgow 
Angle,  E.  J.,  Lincoln,  Neb. 
Anthony,  Henry  G.,  Chicago 
Arning,  Ed.,  Hamburg 
Arnold,  Will  Ford,  Washington,  D.  C. 
Ayrignac,  G.,  Paris 
deAmicis  Tommaso,  Naples 
deAragao,  Egaz  M.  B.,  Bahia,  Brazil 
deAzua,  Juan,  Madrid 

Baer,  Clarence  A.,  Baltimore 
Balzer,  Felix,  Paris 
Baptista,  Virgilio,  Lisbon 
Barrios,  Benet  R.,  Barcelona 
Baum,  William  L.,  Chicago 
Bayet,  A.,  Brussels 
Beck,  Carl,  New  York 
Berk,  A.  B.,  New  York 
Bengoechea,  Ram6n,  New  York 
Bernaldez,  Francisco,  City  of  Mexico 
Bernauer,  Emil  C.,  Brooklyn,  N.  Y. 
Bertarelli,  Ambrogio,  Milan 
Besnier,  Ernest,  Paris 
Biddle,  Andrew  P.,  Detroit 
Bierhoff,  Frederic,  New  York 
Blanck,  S.,  Potsdam 
Bleiman,  A.,  New  York 
Boeck,  C.,  Christiania 
Boggs,  Russell  H.,  Pittsburg 
Bonnet,  Nice 

Bosellini,  Ludovico,  Bologna 
Bowen,  John  T.,  Boston 
Bowman,  L.,  New  York 
Bradley,  Mark  S.,  Hartford 
Breakey,  W.  F.,  Ann  Arbor 


Brinckerhoff,  Walter  R.,  Honolulu 

Brinckley,  G.  O.,  Savannah 

Brocq,  L.,  Paris 

Bronson,  Edward  B.,  New  York 

Bryant,  Joseph  D.,  New  York 

Bufford,  John  H.,  Boston 

Bull,  Thomas  M.,  Naugatuck,  Conn. 

Bulkley,  L.  Duncan,  New  York 

Burnett,  Phillip,  Montreal 

Burns,  Frederick  S.,  Boston 

Buschke,  A.,  Berlin 

Butler,  George  E.,  Fall  River 

Cain,  Maude  F.,  Springfield 
Calkins,  Gary  N.,  New  York 
Campana,  Roberto,  Rome 
Campbell,  G.  Gordon,  Montreal 
Campbell,  R.  R.,  Chicago 
Carmichael,  Randolph  B., 

Washington,  D.  C. 
Caspary,  J.,  KOnigsberg 
Castellani,  Aldo,  Colombo,  Ceylon 
Castelli,  Enrico,  New  York 
Castello,  Jeronimo,  Barcelona 
Cedercreutz,  Axel,  Helsingfors 
Chace,  Fenner  A.,  Fall  River 
Chambers,  Graham,  Toronto 
Ciarrocchi,  Gaetano,  Rome 
Clark,  A.  Schuyler,  New  York 
Cocks,  Edmund  L.,  New  York 
Collings,  S.  P.,  Hot  Springs,  Ark. 
Colombini,  Pio,  Sardinia 
Corlett,  William  T.,  Cleveland 
Councilman,  William  T.,  Boston 
Crary,  George  W.,  New  York 
Crocker,  H.  Radcliffe,  London 

Dade,  Charles  T.,  New  York 
Davis,  C.  N.,  Philadelphia 
Davis,  Robert  H.,  St.  Louis 
Dardel,  Jean,  Aix-les-Bains 


10 


MEMBERS  OF  THE  CONGRESS 


Darier,  J.,  Paris 

Dillingham,  Frederick  H.,  New  York 

Dittrich,  Eberhard  W.,  New  York 

Dohi,  K.,  Tokio 

Doutrelepont,  J.,  Bonn 

Doyon,  A.,  Uriage  (I sere) 

Dreyer,  Albert,  Cologne 

Dubois-Havenith,  Brussels 

Dubreuilh,  William,  Bordeaux 

Duhot,  Brussels 

Dyer,  Isadore,  New  Orleans 

Echeverria,  Emilio, 

Limon,  Costa  Rica 
Ehlers,  E.,  Copenhagen 
Ehrmann,  S.,  Vienna 
Eichhoff,  J.,  Elberfeld 
Elliot,  George  T.,  New  York 
Endokimow,  Victor,  Charkow 
Engman,  Martin  F.,  St.  Louis 
Ern6,  Ivanyi,  Budapest 
Evans,  Melville  G.,  Eugene,  Ore. 
Ewing,  William  B.,  Pittsburg 
von  Eberts,  E.  M.,  Montreal 

Falcao,  Zeferino,  Lisbon 
Fanoni,  A.,  New  York 
Farrell,  John  T.,  Providence 
Finger,  Ernest,  Vienna 
Fischer,  George,  Paterson 
Fischkin,  E.  A.,  Chicago 
Fisher,  G.  M.,  Utica 
Fitzgerald,  Clara  P.,  Worcester 
Foerster,  Otto  H.,  Milwaukee 
Forchhammer,  H.,  Copenhagen 
Fordyce,  John  A.,  New  York 
Foster,  Burnside,    St.  Paul 
Fournier,  Albert,  Paris 
Fox,  Charles  J.,  Hartford 
Fox,  George  Henry,  New  York 
Fox,  Howard,  New  York 
Fox,  T.  Colcott,  London 
Frick,  William,  Kansas  City,  Mo. 

Gaines,  Toulmin,  Mobile 
Galewsky,  Eugen,  Dresden 
Galloway,  James,  London 
Garceau,  Alexander  E. ,  San  Francisco 
Gardner,  Faxton  E.,  New  York 
Gardner,  Gabrielle  D.,  New  York 
Garnett,  A.  S.,  Hot  Springs,  Ark. 
Gastou,  Paul,  Paris 


Gaucher,  Ernest,  Paris 
Gay,  Alexandre,  Kasan 
Gedoelst,  Louis,  Brussels 
Geyer,  Louis  F.  A.,  Zwickau,  Sa. 
Geyser,  A.  C.,  New  York 
Gilchrist,  T.  Caspar,  Baltimore 
Gold,  James  D.,  Bridgeport 
Goldenberg,  Hermann,  New  York 
Gottheil,  William  S.,  New  York 
Grin  don,  Joseph,  St.  Louis 
Grosz,  Siegfried,  Vienna 
Grunfeld,  A.  I.,  Odessa 
Guiteras,  Ramon,  New  York 
Gwathmey,  James  T.,  New  York 
de  Galatz,  Petrini,  Bucharest 

Haase,  Marcus,  Memphis 
Hallopeau,  H.,  Paris 
Hansen,  A.,  Bergen 
Hardaway,  William  A.,  St.  Louis 
Harding,  George  F.,  Boston 
Harmon,  George  E.  H.,  Brooklyn 
Harris,  Samuel  B.,  New  York 
Harttung,  Breslau 
Hartzell,  Milton  B.,  Philadelphia 
Havas,  A.,  Budapest 
Hay,  Eugene  C.,  Hot  Springs,  Ark. 
Hazen,  H.  H.,  Baltimore 
Heidingsfeld,  M.  L. ,  Cincinnati 
Henle,  Pearl  H.,  New  York 
Hirschler,  Rose,  Philadelphia 
Hodgson,  John  H.  P.,  New  York 
Hoffmann,  Erich,  Berlin 
Holder,  Oscar  H.,  New  York 
Hopf,  Friedrich  E.,  Dresden 
Howe,  J.  S.,  Boston 
Htigel,  Georges,  Strassburg 
Hutchinson,  Jonathan,  London 
Hyde,  James  Nevins,  Chicago 

Jack,  James  M.,  Montreal 
Jackson,  George  T.,  New  York 
Jackson,  Jans,  Los  Angeles 
Jadassohn,  J.,  Berne 
Jagle,  Elizabeth  C.,  New  York 
Jamieson,  W.  Allan,  Edinburgh 
Jappe,  C.  F.,  Davenport,  Iowa 
Jeffrey,  Stewart  L.,  Yonkers 
Jenner,  Albert  G.,  Milwaukee 
Jewett,  Mary  B.,  New  York 
Johnston,  James  C.,  New  York 


MEMBERS  OF  THE  CONGRESS 


ii 


Jullien,  Louis,  Paris 

Kanoky,  J.  Phillip,  Kansas  City,  Mo. 
Keyes,  Edward  L.,  New  York 
Keyes,  Edward  L.,  Jr.,  New  York 
de  Keyser,  L.,  Brussels 
Kinch,  Charles  A.,  New  York 
King,  J.  C.  Elliott,  Portland,  Ore. 
King,  James  M.,  Nashville 
Kingsbury,  Jerome,  New  York 
King-Smith,  D.,  Toronto 
Kirby-Smith,  J.  T.,  Sewanee,  Tenn. 
Klotz,  Hermann  G.,  New  York 
Knaffl-Lenz,  Erich,  Graz 
Knowles,  Frank  C.,  Philadelphia 
Krefting,  R.,  Christian ia 
Kromayer,  Ernst,  Berlin 

Lanahan,  Joseph  A.,  Albany 
Lang,  E.,  Vienna 
Lanz,  A.,  Moscow 
Lanzi,  G.,  Rome 
Lapowski,  Boleslaw,  New  York 
Larned,  Ezra  R.,  Detroit 
Lassar,  Oscar,  Berlin 
Lassueur,  Auguste,  Lausanne 
Lawrence,  Herman,  Melbourne 
Lea,  Juanita  I.,  Detroit 
Leredde,  L.  E.,  Paris 
Lespinasse,  Victor  D.,  Chicago 
Lesser,  E.,  Berlin 
Leviseur,  Frederic  J.,  New  York 
LeVy-Bing,  Alfred,  Paris 
Lewis,  Daniel,  New  York 
Lieberthal,  David,  Chicago 
Likes,  Sylvan  H.,  Baltimore 
Lombardo,  Cosimo,  Modena 
L6pez,  Fe'licisimo,  New  York 
Lovejoy,  Edward  D.,  New  York 
Loxton,  William  A.,  Birmingham 
Lusk,  Thurston  G.,  New  "£ork 
Lustgarten,  Sigmund,  New  York 
Lyle,  Halsey  M.,  Kansas  City,  Mo. 
Lyons,  John  J.,  Brooklyn,  N.  Y. 

MacDonald,  Belle  J.,  New  York 
MacKee,  George  M.,  New  York 
Maynard,  O.  T.,  Elyria,  O. 
McBride,  William,  Kansas  City,  Mo. 
McGavock,  Edward  P.,  New  York 
McGowan,  Granville,  Los  Angeles 


McLean,  N.  T.,  Washington,  D.  C. 
McMurray,  W.,  Sydney,  N.  S.  W. 
Meek,  Edith  R.,  Boston 
de  Mello  Breyner,  Thomaz,  Lisbon 
Manage,  H.  E.,  New  Orleans 
Mendes  DaCosta  S.,  Amsterdam 
Metzger,  Jeremiah,  New  York 
Mewborn,  A.  D.,  New  York 
Mibelli,  Vittorio,  Parma 
Michailovsky,  M.,  New  York 
Mink,  O.  J.,  Washington,  D.  C. 
Miller,  R.  M.,  Vienna 
Moller,  Magnus,  Stockholm 
Montgomery,  Douglass  W., 

San  Francisco 

Montgomery,  Frank  H.,  Chicago 
Mook,  William  H.,  St.  Louis 
Morris,  Malcolm,  London 
Morrow,  Howard,  San  Francisco 
Morrow,  Prince  A.,  New  York 
Mount,  Louis  B.,  Troy 
Mullern-Aspegren,  U.,  Stockholm 
Myers,  Lotta  W.,  New  York 

Nadler,  Alfred  G.,  New  Haven 
Neuberger,  Josef,  Nuremberg 
Newman,  Emanuel  D.,  Newark 
Nicolas,  J.,  Lyons 
von  Niessen,  Max,  Wiesbaden 
Noyes,  A.  W.  Finch,  Melbourne 

Oberndorfer,  I.  Pierce,  New  York 

O'Brien,  C.  M.,  Dublin 

Ochs,  Benjamin  P.,  New  York 

Ohmann-Dumesnil,  A.  H.,  St.  Louis 

Olavide,  J.  E.,  Madrid 

Olliphant,  S.  R.,  New  York 

Oltramare,  Geneva 

Oppenheim,  M.,  Vienna 

Ormsby,  Oliver  S.,  Chicago 

Oulmann,  Ludwig,  New  York 

Parounagian,  M.  B.,  New  York 
Peet,  Edward  W.,  New  York 
Fernet,  George,  London 
Peter,  W.,  KOnigsberg 
von  Peterson,  O.,  St.  Petersburg 
Pfahler,  George  E.,  Philadelphia 
Phillipson,  A.,  Hamburg 
Pick,  F.  T.,  Prague 
Pisko,  Edward,  New  York 
Pittman,  John  G.,  Chattanooga 


12 


MEMBERS  OF  THE  CONGRESS 


Pizzini,  Tancredi,  Milan 
Plumley,  W.  Franklin,  Rochester 
Polland,  Rudolf,  Graz 
Pollitzer,  Sigmund,  New  York 
Pontoppidan,  E.,  Copenhagen 
Pospelow,  A.  J.,  Moscow 
Post,  Abner,  Boston 
Potter,  Alfred,1  Brooklyn,  N.  Y. 
Pringle,  J.  J.,  London 
Pudor,  G.  A.,  Portland,  Me. 
Pusey,  William  A.,  Chicago 

Quinn,  William  A.,  Chicago 

Rasch,  Carl,  Copenhagen 
Ravitch,  M.  L.,  Louisville 
Ravogli,  Augustus,  Cincinnati 
Regensburger,  Alfred,  San  Francisco 
Regidor,  A.  Pardo,  Madrid 
Remsen,  Ira,  Baltimore 
Renault,  Alex.,  Paris 
Riehl,  G.,  Vienna 
Rixey,  P.  M.,  Washington,  D.  C. 
Robelin,  Henry,  Havana 
Robinson,  Andrew  R.,  New  York 
Robinson,  Daisy  M.  O.,  New  York 
Robinson,  William  J.,  New  York 
Roca,  Joseph  M.,  Barcelona 
Rona,  S.,  Budapest 
Rosenthal,  Melvin,  Baltimore 
Rosenthal,  O.,  Berlin 
Rosolimos,  Sp.,  Athens 
Ruggles,  E.  Wood,  Rochester 

Satenstein,  David  L.,  New  York 
Schamberg,  Jay  F.,  Philadelphia 
Schmidt,  Louis  E.,  Chicago 
Schoney,  L.,  New  York 
Schroeder,  H.  H.,  New  York 
Schultz,  Oscar  T.,  Cleveland 
Schumacher,  Carl  II.,  Aachen 
Schwartz,  Hans  J.,  New  York 
Selenew,  J.  Th.,  Charkow 
Selhorst,  S.  B.,  The  Hague 
Sequeira,  James  H.,  London 
Shattuck,  George  C.,  Boston 
Shelmire,  Jesse  B.,  Dallas 
Shepherd,  Francis  J.,  Montreal 
Sherwell,  Samuel,  Brooklyn,  N.  Y. 
Shields,  Edward  H.,  Cincinnati 
Simpson,  Frank  E.,  Chicago 


Smith,  C.  Morton,  Boston 
Sociedad  Dermatologica  Argentina 

Buenos  Ayres,  S.  A. 
Sohn,  David  L.,  New  York 
Sol,  Juan,  Barcelona 
Sommer  Baldomero, 

Buenos  Ayres,  S.  A. 
Spangenthal,  J.,  Buffalo 
Stelwagon,  Henry  W.,  Philadelphia 
Stern,  Samuel,  New  York 
Stevens,  Rollin  H.,  Detroit 
Stiles,  Ch.  Wardell,  Washington,  D.  C. 
Stitt,  E.  R.,  Washington,  D.  C. 
Strebel,  H.,  Munich 
Sturgis,  Frederick  R.,  New  York 
Sumney,  Herbert  C.,  Omaha,  Neb. 
Swift,  Homer  F.,  New  York 
Swinburne,  George  K.,  New  York 

Tanaka,  Tomoharu,  Tokio 
Taylor,  G.  G.  Stopford,  Liverpool 
Taylor,  Robert  W.,  New  York 
Terzaghi    Rome 
Thibierge,  Georges,  Paris 
Thorndike,  Townsend  W.,  Boston 
Throne,  Binford,  Brooklyn,  N.  Y. 
Towle,  Harvey  P.,  Boston 
Trimble,  William  B.,  New  York 
Tucker,  Edwin  D.,  Toledo 
Tyzzer,  E.  E.,  Boston 

Unna,  P.  G.,  Hamburg 

Uruefia,  Jesus  Gonzales,  Mexico  City 

Valdes-Morel,  Alberto,  Santiago,  S.  A. 
Valente,  Frederico,  Lisbon 
Van  Harlingen,  Arthur,  Philadelphia 
Varney,  H.  Rockwell,  Detroit 
Veiel,  Theodor, 

Cannstatt,  Wurttemberg 
Vermilye,  Robert  M.,  New  York 
Vifieta-Bellaserra,  Jose",  Barcelona 

Wallhauser,  H.  J.,  Newark,  N.  J. 
Ware,  Martin  W.,  New  York 
Weiss,  Ludwig,  New  York 
Welander,  Edward,  Stockholm 
Wende,  Ernest,  Buffalo 
Wende,  Grover  W.,  Buffalo 
White,  Charles  J.,  Boston 
White,  James  C.,  Boston 


MEMBERS  OF  THE  CONGRESS          13 

Whitehouse,  Henry  H.,  New  York  Winfield,  James  M.,  Brooklyn,  N.  Y. 

Whitfield,  Arthur,  London  Wise,  Fred,  New  York 

Wickham,  Louis,  Paris  Wolff,  Alfred,  Strassburg 
Williams,  Arthur  U., 

Hot  Springs,  Ark.  deYelnitsky,  Stanislas,  Lodz 

Williams,  Charles  M.,  New  York  Zambaco  Pasha,  Constantinople 

Williams,  Ralph,  Los  Angeles  Zeisler,  Joseph,  Chicago 

Wilson,  Omar  M.,  Ottawa  von  Zumbusch,  Leo,  Graz 


DELEGATES 

Dr.  L.  DeKeyser,  of  Brussels,  for  Belgium. 

Dr.  Carl  Rasch,  of  Copenhagen,  for  Denmark  and  the  Uni- 
versity of  Copenhagen. 

Dr.  Ricardo  Sudrez  Gamboa,  of  the  City  of  Mexico,  for 
Mexico. 

Mr.  S.  C.  Maximos,  Acting  Consul  in  New  York  City,  for 
Greece. 

Dr.  Felicisimo  L6pez,  Consul-General  in  New  York  City, 
for  Ecuador. 

Dr.  Ramon  Bengoechea,  Consul-General  in  New  York  City, 
for  Guatemala. 

Dr.  H.  Radcliffe-Crocker,  of  London,  for  the  Dermatologi- 
cal  Society  of  London. 

Dr.  H.  Hallopeau,  Dr.  Paul  Gastou,  and  Dr.  Alex.  Renault, 
of  Paris,  for  the  French  Dermatological  Society. 

Prof.  Erich  Hoffmann,  of  Berlin,  for  the  Berlin  Dermato- 
logical Society. 

Dr.  Ambrogio  Bertarelli,  of  Milan,  for  the  Italian  Dermato- 
logical Society. 

Dr.  Victor  Endokimow,  of  Charkow,  for  the  Charkow  Der- 
matological Society  and  the  University  Clinic  of  Prof.  Selenew. 

Dr.  A.  I.  Grunfeld,  of  Odessa,  for  the  Dermatological  Soci- 
etyJof^Odessa. 

Dr.  L.  DeKeyser  and  Dr.  Dubois-Havenith,  of  Brussels, 
for  the  Belgian  Dermatological  Society. 


Sixth  International  Dermatological  Congress 

Held  at  the  ACADEMY  of  MEDICINE,  New  York  City,  September 
9th  to  1 4th,  1907 

FIRST   DAY,  MONDAY,  SEPTEMBER  9TH 

The  morning  session  was  called  to  order  at  10.15  A-M- 
by  THE  PRESIDENT,  Dr.  JAMES  C.  WHITE,  of  Boston.  He  said 
that  before  proceeding  to  the  exercises  of  the  opening  session 
of  the  Congress  it  would  be  necessary  to  take  the  usual  prelim- 
inary steps  for  its  organization,  and  he  therefore  asked  the 
attention  of  the  members  to  the  report  of  the  Secretary- 
General  upon  the  work  of  the  Organization  Committee  since 
the  meeting  of  the  Congress  at  Berlin  in  1904. 

By  authority  there  conferred  upon  him,  he  had  appointed 
to  that  important  and  laborious  office  Dr.  John  A.  Fordyce  of 
New  York,  who  would  now  read  the  names  of  the  Committee 
of  Organization  subsequently  chosen,  and  of  the  persons 
selected  to  fill  the  various  offices  for  this  Congress,  and  he  would 
ask  the  members  at  the  close  of  the  report  to  vote  upon  the 
ratification  of  these  nominations. 

SECRETARY-GENERAL'S  REPORT 

DR.  JOHN  A.  FORDYCE  spoke  as  follows: 

Gentlemen :  The  International  Congress  of  Dermatology 
for  the  first  time  since  its  organization  convenes  on  this  side 
of  the  Atlantic.  It  is,  therefore,  a  great  pleasure  to  me,  as 
Secretary-General,  to  say  the  first  word  of  welcome,  which  I 
extend  most  cordially  to  all  of  our  visiting  members  and  dele- 
gates. Under  our  existing  national,  state,  and  municipal 
governments  it  is  not  generally  customary  to  lend  financial  or 
other  aid  to  international  scientific  bodies,  so  that  failure  to  ob- 
serve old-world  methods  must  not  be  construed  as  indifference 

15 


16  SIXTH  INTERNATIONAL 

on  their  part  to  the  success  of  our  undertaking.  Mr.  Roose- 
velt has  kindly  consented  to  greet  the  members  through 
the  Surgeon-General  of  our  Navy,  Dr.  Rixey.  The  govern- 
ment medical  services,  too,  are  officially  represented  on  our 
programme  by  papers  prepared  by  the  Surgeon-General  of 
the  Navy  and  others.  Dr.  Ira  Remsen,  President  of  Johns 
Hopkins  University,  will  speak  for  educational  institutions, 
and  Dr.  Joseph  D.  Bryant,  President  of  the  American  Medical 
Association,  for  the  medical  profession  of  this  country. 

Invitations  to  foreign  governments  to  be  represented  by 
delegates  have  been  kindly  forwarded  through  our  State 
Department,  and  I  take  pleasure  in  announcing  that  the 
following  gentlemen  have  been  appointed  to  represent  their 
respective  governments : 

Dr.  Carl  Rasch  of  Copenhagen  for  Denmark  and  the  Uni- 
versity of  Copenhagen. 

Dr.  L.  DeKeyser  of  Brussels  for  Belgium. 

Dr.  Ricardo  Su£rez  Gamboa  of  the  City  of  Mexico  for 
Mexico. 

Mr.  S.  C.  Maximos,  Acting  Consul  in  New  York  City,  for 
Greece. 

Dr.  Felicisimo  L6pez,  Consul-General  in  New  York  City, 
for  Ecuador. 

Dr.  Ram6n  Bengoechea,  Consul-General  in  New  York 
City,  for  Guatemala. 

The  following  foreign  societies  send  greetings  through  their 
delegates : 

The  Dermatological  Society  of  London,  Dr.  H.  Radcliffe- 
Crocker,  of  London;  La  Soci£t6  Franchise  de  Dermatologie 
et  de  Syphilogie,  Dr.  H.  Hallopeau,  Dr.  Gastou,  and  Dr. 
A.  Renault  of  Paris;  Berliner  Dermatologische  Gesellschaft, 
Prof.  Erich  Hoffmann  of  Berlin;  Socie~te  Beige  de  Derma- 
tologie et  de  Syphilogie,  Dr.  L.  DeKeyser  and  Dr.  Dubois- 
Havenith  of  Brussels;  Societa  Dermatologia  Italiana,  Dr. 
Ambrogio  Bertarelli  of  Milan;  Dermatological  Society  of 
Odessa,  Dr.  A.  I.  Grunfeld  of  Odessa;  the  Charkow  Derma- 
tological Society  and  the  University  Clinic  of  Prof.  Selenew, 
through  Dr.  Victor  Endokimow. 

This  Congress  owes  its  origin  to  the  request  of  a  committee 


DERMATOLOGICAL  CONGRESS  17 

elected  by  the  American  Dermatological  Association  and  the 
Dermatological  Section  of  the  American  Medical  Association 
that  the  Sixth  International  Congress  of  Dermatology  be  held 
in  America  in  1907,  under  the  presidency  of  Dr.  James  C. 
White  of  Boston.  This  invitation  the  Fifth  International 
Dermatological  Congress,  which  met  in  Berlin  in  1904,  was 
pleased  to  accept.  Late  in  the  autumn  of  the  same  year  an 
Organization  Committee  representing  15  cities  was  appointed 
by  Dr.  White.  In  the  following  summer,  one  of  the  members, 
Dr.  Charles  W.  Allen,  from  whom  much  was  expected  on 
account  of  his  energy,  linguistic  accomplishments,  genial 
disposition,  and  wide  acquaintance,  contracted  typhoid  fever 
after  attending  the  International  Medical  Congress  at  Lisbon 
and  died  at  Gibraltar.  You  will  all,  I  am  sure,  share  the  deep 
sorrow  caused  by  Dr.  Allen's  death.  It  is  also  with  deepest 
regret  that  I  refer  to  the  death  of  Prof.  Neumann  of  Vienna, 
Prof.  Haslund  of  Copenhagen,  and  Prof.  Tarnowski  of  St. 
Petersburg,  Vice- Presidents  for  Austria,  Denmark,  and  Russia, 
respectively. 

The  Committee  has  met  at  stated  intervals,  selected  the 
themes  for  formal  discussion,  and  completed  the  list  of  officers 
of  the  Congress  herewith  appended,  with  whom  it  has  co-oper- 
ated in  every  way  in  originating  and  carrying  out  prepara- 
tions which  attend  an  organization  of  this  kind.  The  great 
success  of  the  Berlin  convention  and  of  those  which  preceded 
it  has  been  an  added  stimulus  to  American  dermatologists  to 
prepare  a  scientific  and  social  programme  which  would  prove 
acceptable  to  our  visiting  colleagues.  The  annual  meeting  of 
the  American  Dermatological  Association  was  wisely  omitted 
this  year  so  that  its  members  could  concentrate  their  energies 
in  behalf  of  this  gathering.  Whether  we  have  succeeded  in 
our  efforts  the  work  of  the  coming  week  will  reveal.  The 
Committee  wishes  to  express  its  appreciation  of  the  cordial 
responses  to  requests  for  papers,  clinical  material,  and  other 
assistance.  Those  who  have  been  fortunate  enough  to  attend 
former  Congresses,  since  the  first  session  in  Paris  in  1889, 
will  not  see  such  an  elaborate  exhibition  of  models,  cases,  or 
scientific  apparatus.  This  time  of  the  year,  owing  to  climatic 
conditions,  is  not  a  very  fortunate  one  for  the  exhibition  of 


i8  SIXTH  INTERNATIONAL 

clinical  cases  or  bacteriological  preparations,  as  very  few 
practitioners  are  in  town  and  most  of  the  laboratories  are 
closed  during  the  summer.  We  have  had  in  mind  the  demon- 
stration of  cases  peculiar  to  this  country,  such  as  blastomycetic 
dermatitis  and  skin  diseases  which  affect  the  negro.  Unfor- 
tunately, when  most  needed,  such  cases  are  not  at  our  dis- 
position and  we  are  not  able  to  exhibit  as  many  as  anticipated. 
The  number  of  papers  announced  on  the  programme  is  so 
large  that  it  will  not  be  practicable  to  listen  to  them  all  and  a 
close  observance  of  the  time  limit,  with  some  possible  excep- 
tions, will  have  to  be  insisted  upon. 

It  is  a  matter  of  great  regret  that  so  few  of  our  foreign 
colleagues  have  been  able  to  come.  We  have  with  us,  however, 
delegates  from  Great  Britain,  Germany,  Austria,  France, 
Russia,  Denmark,  Belgium,  Italy,  Spain,  Mexico,  Australia, 
Japan,  Greece,  Ecuador  and  Guatemala;  giving  an  interna- 
tional complexion  to  the  Congress. 

During  the  time  which  has  intervened  since  its  organization, 
we  have  had  the  earnest  support  of  our  foreign  secretaries, 
to  whom  I  desire  to  express  my  cordial  thanks  for  their  assist- 
ance in  promoting  the  interests  of  the  Congress. 

A  number  of  our  colleagues  who  fully  expected  to  be  with 
us  and  contribute  to  our  scientific  programme  have  been  una- 
ble to  do  so,  by  personal  or  family  illness,  and  from  many  of 
them  letters  expressing  regret  have  been  received.  They  are 
as  follows: 

Prof.  Neisser,  Prof.  Lesser,  Sir  McCall  Anderson,  Dr.  W. 
Allan  Jamieson,  Dr.  Pye-Smith,  Mr.  George  Pernet,  Prof. 
Doutrelepont,  Prof.  Finger,  Prof.  Jadassohn,  Dr.  Pringle, 
Prof.  Pontoppidan,  Dr.  Oltramare,  Dr.  Mibelli,  Dr.  Besnier, 
Prof.  Boeck,  Prof.  DeAmicis,  Mr.  Malcolm  Morris,  Dr.  Darier, 
Dr.  Sabouraud,  Prof.  Riehl,  Dr.  T.  Colcott  Fox,  Prof.  Ehlers, 
Dr.  Arning,  Dr.  Buschke,  Dr.  Uruefia,  Prof.  Kromayer,  Dr. 
Lassueur,  Dr.  Rosenthal,  Dr.  Herxheimer,  Dr.  Engelsted. 

I  am  sure  you  will  all  unite  with  me  in  thanking  them  for 
their  wishes  for  a  successful  meeting. 

Although  the  work  of  the  past  three  years  has  been  arduous 
it  has  been  rendered  much  easier  by  the  work  of  my  predecessors 
in  this  office,  and  has  had  its  compensation  in  opportunities 


DERMATOLOGICAL  CONGRESS  19 

for  pleasant  relationship  with  a  vast  number  of  our  colleagues 
in  all  countries  of  the  world.  Whatever  measure  of  success  may 
attend  the  Congress  is  due  to  the  constant  and  painstaking 
efforts  of  its  distinguished  President,  Dr.  James  C.  White, 
who  so  carefully  planned  the  endless  details  which  are  only 
known  to  those  who  have  been  intimately  associated  with 
him. 

In  the  name  of  the  dermatologists  of  America  I  wish  you 
welcome  to  this  country  and  city. 

This  report  was  read  and  duly  ratified,  together  with  the 
list  of  officers. 

THE  PRESIDENT  stated  that  President  Roosevelt,  who 
had  always  shown  great  interest  in  all  questions  of  medical 
science  and  hygiene,  had  requested  the  Surgeon-General  of 
the  Navy,  Dr.  P.  M.  Rixey,  to  offer  a  welcome  to  the  Congress. 

FOR  THE   UNITED  STATES  GOVERNMENT:   AN 
ADDRESS  OF  WELCOME 

BY     SURGEON-GENERAL   P.    M.    RIXEY,  UNITED    STATES  NAVY, 

REPRESENTING   PRESIDENT  ROOSEVELT 

Mr.  President  and  Gentlemen  of  the  Congress:  I  have 
the  honor  and  very  great  pleasure  of  extending  a  hearty 
welcome  to  you  in  the  name  of  our  President,  and  all  that 
he  represents.  His  regret  at  being  unable  to  be  present 
on  this  occasion,  and  his  instructions  to  me  to  convey  his 
greetings  to  you,  as  expressed  in  the  President's  own  words,  is 
best  shown  in  his  letter  under  date  of  July  u,  1907,  from 
Oyster  Bay,  New  York,  which  I  now  read: 

"Sm: — I  shall  be  glad  if  you  will  attend  the  meeting  of  the 
Sixth  International  Dermatological  Congress,  to  be  held  in 
New  York  City,  September  gth  to  i4th,  1907,  and  convey 
to  it  my  appreciation  of  its  invitation  to  be  present  and 
my  regrets  at  not  being  able  to  accept.  Please  greet  in  my 
name  the  Congress,  especially  the  foreign  delegates,  and  wish 
them  a  most  prosperous  meeting. 

"Sincerely  yours, 

"THEODORE  ROOSEVELT." 


20  SIXTH   INTERNATIONAL 

In  accordance  with  this  letter,  I  extend  to  you  a  most 
cordial  welcome  from  the  President  of  the  United  States, 
representing  as  he  does  the  various  national  medical  services, 
as  well  as  the  whole  people.  I  especially  wish  to  extend  this 
greeting  to  the  delegates  from  foreign  countries  who  have 
honored  us  by  their  presence,  and  I  trust  the  occasion  will  be 
the  means  of  forming  many  ties  that  may  be  mutually  bene- 
ficial. The  coming  together  of  such  bodies  of  men  as  I  see 
before  me  this  morning,  experts  in  learning  and  specialists  in 
the  great  field  of  dermatology,  cannot  but  be  productive  of 
much  good  to  suffering  humanity,  not  only  of  this  but  of  every 
country  here  represented. 

The  universal  interest  that  our  President  takes  in  all  matters 
pertaining  to  the  welfare  of  the  human  race,  whether  it  be 
physical,  mental,  or  moral,  is  too  well  known  and  has  been 
exemplified  in  his  whole  career  too  clearly  to  need  from  me 
more  than  a  passing  reference;  but  it  may  never  be  known 
how  much  he  has  been  interested  in  and  has  done  for  the 
medical  profession  until  one  has  been  as  intimately  connected 
with  this  work  as  I  have  been.  I  therefore  take  this  op- 
portunity of  saying  that  in  the  history  of  Presidents,  I  may 
say  of  rulers,  there  has  been  none  who  has  been  more  interested 
in  the  progress  of  the  medical  profession,  as  well  as  every 
legitimate  field  of  work,  than  Theodore  Roosevelt.  In  the 
national  field  of  medical  work,  of  one  branch  of  which  I  have 
the  honor  to  be  the  head, — and  consequently  have  had  an 
intimate  knowledge  of  the  sister  services, — I  have  the  deepest 
sense  of  our  obligations  and  personal  love  for  the  representative 
of  a  great  people  who  stands  for  justice  to  all  and  has  the 
firmness  to  see  that  justice  accomplished,  especially  toward 
those  physically  afflicted.  Those  of  us  who  have  had  charge 
of  such  work  thoroughly  appreciate  what  it  is  to  have  matters 
carefully  weighed  and  justice  done  as  it  has  been  under  our 
present  President.  I  speak  feelingly  of  all  this.  It  means 
more  than  words  can  express  to  one  who  had  come  to  the  head 
of  the  Bureau  of  Medicine  and  Surgery  of  the  Navy  five 
years  ago,  which  at  that  time  was  sorely  in  need  of  all  that 
great  advance  which  was  being  made  by  our  civil  brethren. 
An  account  of  stocktaking  at  that  time  showed  a  corps  of 


DERMATOLOGICAL   CONGRESS  21 

medical  officers  one-half  short  as  to  numbers,  no  opportunity 
for  advancement  in  their  profession,  and  ground  down  by 
routine  work;  ships  and  hospitals,  so  far  as  the  sick  and 
injured  were  concerned,  out  of  date  and  wanting  in  modern 
facilities  for  the  care  of  those  afflicted.  We  can  now  show 
a  wide-awake  working  corps,  with  advantages  in  professional 
and  even  research  work  that  may  well  be  the  envy  of  our 
civil  brethren;  a  post-graduate  medical  school  and  a  new 
naval  medical  school  hospital  at  Washington;  a  number  of 
new  naval  hospitals  at  home  and  abroad,  and  the  old  ones 
being  modernized  as  rapidly  as  possible;  our  battleships  and 
cruisers  having  space  assigned  to  the  sick  and  injured,  fitted 
in  accordance  with  modern  methods.  In  addition  to  all  this, 
the  standing  of  the  medical  officer  is  on  a  fair  basis;  as  with 
the  Navy  so  with  the  sister  services.  All  this  has  been  ac- 
complished, gentlemen,  because  we  have  had  in  the  White 
House  one  who  only  needs  to  know  of  defects  and  injustice 
to  overcome  them.  No  wonder  that  I  state  here  before 
you  to-day  that  the  medical  profession  has  much  to  place  to  his 
credit,  and  in  the  future  we  can  rely  upon  his  hearty  co- 
operation in  any  efforts  for  the  general  well-being.  He  takes 
a  deep  interest  in  all  that  concerns  the  medical  profession,  and, 
realizing  our  need  for  help  and  assistance,  never  loses  an  op- 
portunity to  strengthen  and  support  us  in  the  many  pro- 
gressive steps  we  have  taken.  So  you  may  feel  assured  that 
he  will  take  a  special  interest  in  the  proceedings  of  this  Con- 
gress, and  joins  with  us  in  the  hope  that  from  its  deliberations 
much  good  may  be  derived. 

During  the  past  twenty  years  the  subject  of  skin  diseases, 
which  we  have  met  here  to  consider,  has  received,  with  all 
other  medical  subjects,  a  great  impetus.  The  introduction 
of  laboratory  methods  has  opened  up  a  world  of  useful  infor- 
mation, and  especially  to  those  of  us  in  the  Government 
services  the  period  has  been  one  of  constant  advance  and 
discovery,  brought  about  particularly  by  our  advent  into 
tropical  and  heretofore  little  known  countries.  So  im- 
portant has  the  subject  become  that  we  are  now  bending 
our  efforts  to  perfect  the  members  of  the  medical  corps 
of  the  services  in  a  knowledge  of  this  specialty  and  to 


22  SIXTH   INTERNATIONAL 

equip  them  for  practical  and  research  work  in  all  parts  of 
the  world. 

I  have  been  more  than  pleased  at  the  active  steps  taken 
by  this  Congress  to  demand  from  educational  institutions  more 
careful  consideration  of  the  study  of  diseases  of  the  skin;  to 
require  more  study  and  deeper  insight  into  this  very  important 
branch  of  medical  science. 

In  our  naval  medical  work  I  find  upon  investigation  that 
the  proportion  of  dermatological  diseases  to  all  others  is 
about  13  per  cent.  This  shows  clearly  how  our  interests  must 
be  in  your  special  work,  and,  therefore,  we  seek  as  close  an  af- 
filiation with  the  object  of  this  meeting  as  is  practicable. 
Following  out  this  idea,  we  of  the  Navy,  at  our  post-graduate 
medical  school  in  Washington,  are  giving  more  and  more 
attention  to  skin  troubles,  both  in  our  didactic  teaching  and 
in  the  laboratory,  and  many  of  our  most  interesting  reports 
to-day  are  on  this  subject,  especially  in  connection  with  tropical 
medicine. 

Once  more  I  give  you  a  most  hearty  welcome  from  our 
chief  magistrate,  and  hope  that  this,  the  Sixth  Meeting  of 
the  International  Dermatological  Congress,  may  be  one  long 
to  be  remembered  for  the  good  it  has  accomplished. 

THE  PRESIDENT  said  that  all  recognized  the  great  impor- 
tance of  the  relations  existing  between  the  university  and 
schools  of  medicine;  the  elevating  and  fostering  influence  of 
the  one,  the  completeness  and  strength  afforded  by  the  other. 
It  was  most  fitting  that  the  distinguished  President  of 
Johns  Hopkins  University  of  Baltimore,  which  had  occupied 
so  prominent  a  position  in  raising  and  sustaining  the  standard 
of  medical  education  in  this  country,  and  was  so  conspicuous 
in  the  high  character  of  the  instruction  it  had  given,  should 
be  asked  to  speak  for  all  American  universities.  He  took 
great  pleasure,  therefore,  in  presenting  Dr.  Ira  Remsen. 

THE  AMERICAN  UNIVERSITIES 

PRESIDENT  IRA  REMSEN  said:  I  esteem  it  a  great  honor 
to  be  permitted  to  appear  before  this  Congress  and  express 
a  welcome  on  behalf  of  the  universities  of  this  country,  espe- 


DERMATOLOGICAL   CONGRESS  23 

cially  to  those  members  who  have  come  from  foreign  coun- 
tries, and  I  sincerely  hope  that  the  work  of  the  Congress 
may  in  every  respect  be  pleasant  and  profitable. 

Why  a  representative  of  the  American  universities  should 
be  called  upon  in  this  capacity  is  a  question  that  I  have  pon- 
dered over  a  good  deal  since  I  have  been  invited,  and  why 
I  have  been  especially  selected  to  represent  the  universities 
has  caused  me  a  little  worry  since  I  have  been  rash  enough 
to  accept  the  invitation.  Personally,  I  have  retained  a  certain 
interest  in  the  medical  profession  because  in  my  early  years 
I  became  the  proud  possessor  of  the  degree  of  M.D.  My 
knowledge  of  medicine,  however,  is  like  beauty  in  one  respect, 
only  skin  deep,  and  perhaps  it  was  for  that  reason  that  I 
have  been  selected  for  this  occasion.  But  to  return  to  the 
question  why  a  representative  of  American  universities  should 
be  called  upon  to  speak  before  a  Congress  of  this  kind.  The 
reason  for  the  existence  of  this  Congress  is  research.  The 
members  have  come  together  to  discuss  the  results  of  their 
own  researches,  and  the  results  of  the  researches  of  their 
co-workers.  The  universities  are  the  training  grounds  of  re- 
search ;  that  point  is  perfectly  clear.  While  research  might  be 
carried  on  to  a  certain  extent  without  the  university,  after 
all,  its  success  depends  primarily  on  the  university.  This 
fact  has  come  to  be  recognized  in  medical  circles  in  this  coun- 
try, and  there  is  at  present  a  well-defined  university  move- 
ment among  the  medical  schools. 

Not  many  years  ago,  the  relation  between  the  medical 
school  and  the  university  was  largely  nominal.  There  is,  to 
be  sure,  a  medical  school  at  Harvard,  and  one  in  New  York, 
the  College  of  Physicians  and  Surgeons — of  which  I  am  an 
alumnus — which  is  connected  with  Columbia  College,  but  the 
connection  between  the  two  was  formerly  only  nominal. 
During  the  past  twenty-five  years,  however,  this  university 
movement  has  acquired  a  great  momentum.  The  universities 
are  taking  possession  of  the  medical  schools,  and  the  medical 
schools  are  trying  to  get  under  the  cover  of  the  universities. 
I  am  afraid  if  this  movement  keeps  up  there  will  not  be  enough 
universities  to  go  around,  for  there  are  a  large  number  of 
medical  schools  that  now  recognize  the  advantages  of  a 


24  SIXTH   INTERNATIONAL 

university  connection.  What  are  those  advantages ?  That  is 
a  broad  question,  and  I  will  not  attempt  to  answer  it  in  the 
few  minutes  at  my  disposal,  but  will  limit  myself  to  a  few- 
words  on  this  subject.  It  is  perhaps  not  clearly  recognized  by 
all,  but  by  the  leaders  in  the  movement  it  is  recognized  that 
the  atmosphere  of  research  is  the  best  atmosphere  for  teach- 
ing, and  that  I  take  to  be  the  fundamental  point  in  connection 
with  this  university  movement.  This  fact  is  recognized  in 
most  countries,  and  is  coming  to  be  recognized  more  and  more 
in  this  country. 

Another  reason  why  the  medical  schools  are  coming  under 
the  university  banner  is  this:  Not  long  ago,  the  medical 
school  was  a  profitable  business  and  it  was  kept  up  partly  for 
that  reason.  But  that  day  has  gone  or  certainly  is  going,  and  the 
fact  has  become  apparent  that  it  is  very  expensive  to  properly 
conduct  a  medical  school.  It  requires  money  and  it  requires 
endowments,  and  none  can  hope  to  survive  without  these. 
The  medical  schools  and  the  medical  departments  of  univer- 
sities are  now  on  the  same  footing  as  are  other  kinds  of  higher 
education.  The  old-fashioned  medical  school  can  not  hope  for 
any  endowment  in  the  ordinary  course  of  events,  whereas 
the  universities  have  been  fortunate  enough  to  receive  them. 
There  are  therefore  two  reasons  why  the  relationship  between 
the  medical  schools  and  the  universities  is  becoming  closer,  and 
because  of  that  fact  there  is  perhaps  some  reason  for  inviting 
a  representative  of  an  American  university  to  appear  before 
this  Congress,  the  work  of  which  is  wholly  given  to  medicine. 

THE  PRESIDENT  said  that  Dr.  Joseph  D.  Bryant,  the 
President  of  the  American  Medical  Association,  some  67,000 
strong,  would  now  welcome  the  Congress  in  the  name  of  the 
medical  profession  of  the  United  States. 

FOR  THE  MEDICAL  PROFESSION  OF  THE 
UNITED  STATES 

DR.  BRYANT  made  the  following  address : 
Mr.  President,  Distinguished  Guests,  and  Members 
of  the  Sixth  International  Dermatological  Congress: 
I  am  delighted  and  honored  by  the  opportunity  of  greeting 


DERMATOLOGICAL   CONGRESS  25 

you  and  extending  the  fraternal  welcome  which  the  members 
of  the  American  Medical  Association  gladly  bestow  on  all 
those  who  labor  in  the  advancement  of  medical  attainment 
and  for  the  relief  of  human  affliction.  And  I  hope  that  I 
may,  with  perfect  propriety,  also  greet  you  in  behalf  of  the 
medical  profession  of  the  country,  of  which  there  are  about 
112,000  whom  we  may  regard  as  scientifically  anointed  breth- 
ren. Consequently,  the  very  many  extend  to  the  comparative 
few  the  joyous  welcome  akin  to  that  with  which  the  expect- 
ant family  circle  greets  the  homecoming  of  a  highly  esteemed 
and  honored  member  of  its  own  number.  To  the  branch  of 
our  professional  family  which  you  so  fittingly  represent,  be- 
long infinite  praise  and  profound  congratulation  because  of 
the  eminent  success  which  has  attended  your  efforts,  in  a 
difficult  and  often  perplexing  field  of  professional  activity. 
For  the  especial  part  of  the  human  body  to  which  your  atten- 
tion and  skill  are  directed  is  the  one  most  often  associated 
in  the  human  mind  with  peculiar  feelings  of  pride  and  an 
abiding  sense  of  gratification,  so  long,  at  the  least,  as  "  beauty 
doth  banish  age."  Sometimes  no  doubt  the  brightest  hopes 
in  your  professional  endeavor  are  clouded  by  the  miscon- 
ceptions of  the  fairminded  and  the  murmurings  of  the  dis- 
contented, relating  to  cosmetic  prospects  of  uncertain  tenure 
or  of  established  outcome. 

Let  us,  however,  soften  the  sombre  aspects  of  this  picture 
a  bit  by  emollient  facts  as  expressed  by  the  poet  (Gay)  who 
said: 

"In  beauty  faults  conspicuous  grow; 
The  smallest  speck  is  seen  in  snow. " 

We  should,  however,  remember  that  in  this  connection  mis- 
giving and  prejudice  disappear  and  thankfulness  rules,  as  the 
rewards  of  gratitude  and  duty  come  into  view. 

The  welcome  on  this  occasion  is  no  less  pronounced  nor 
deserved  because  of  the  facts  that  in  professional  communion 
with  each  other  you  will  speak  blithefully,  and  seemingly  with 
mutual  understanding  and  with  untripping  tongue,  in  a  pro- 
fessional language  whose  classified  forms  of  expression  often 


26  SIXTH   INTERNATIONAL 

startle  the  unsuspecting,  astonish  the  unsophisticated,  and 
torment  the  wise. 

The  amplitude  of  the  welcome  which  we  extend  to  you 
is  as  broad  as  our  country  and  as  deep  as  is  its  substance, 
therefore,  comparatively  as  broad  as  is  the  field  of  your  pro- 
fessional activities,  and  as  deep — reaching  from  the  surface 
to  the  centre,  from  the  skin  to  the  stomach,  as  illustrated  by 
the  co-operative  activity  of  the  pernicious  pie  and  the  per- 
sistent pimple — marking  time  together. 

We  expect  much  of  you,  we,  who  have  been  so  bountifully 
served  already,  in  personal  welfare  and  comfort,  yet  are  in- 
clined to  desire  more.  And  that  our  wishes  in  this  regard 
will  be  realized  in  a  beneficent  way  is  emphasized  by  the 
scope  and  scientific  fertility  of  the  program  of  professional 
attainment  placed  before  us  for  consideration. 

Those  who  came  from  abroad,  we  especially  desire  will 
remain  long  enough  with  us  to  know  more  of  our  great  country 
and  of  its  people,  to  pay  homage  to  the  prodigal  manifesta- 
tions of  nature's  labors  which  everywhere  beautify  and  dignify 
this  broad  country  of  ours.  You  have  lofty  peaks,  so  have 
we;  you  have  wide  rivers,  beautiful  lakes,  and  health-giving 
springs,  so  have  we  in  profuse  abundance.  You  have  broad 
plains  and  fertile  soil  and  abundant  crops,  so  have  we,  broader 
plains  with  fertile  soil  and  abundant  crops,  tilled  and  beauti- 
fied by  the  poor  and  the  oppressed  of  all  nations. 

And  now,  kindly  pardon  what  I  trust  is  an  excusable 
pride  in  requesting  that  you  note  the  professional  attractions 
of  the  building  in  which  you  are  assembled,  and  heed  the 
lesson  which  it  teaches.  Note  the  extent  of  its  medical  library 
second,  I  believe,  to  but  one  in  our  country,  remembering 
the  while  that  this  creation  is  an  earnest  of  the  power  of 
local  cohesive  harmony  begotten  of  professional  pride,  is 
fostered  by  lofty  civic  and  professional  purposes,  and  stimu- 
lated in  contented  advance  by  a  completed  membership  of 
1000,  supplemented  by  a  rapidly  increasing  waiting  list. 

The  67,000  members  of  the  American  Medical  Association 
individually  and  collectively  extend  to  those  of  other  lands 
and  of  their  own  a  most  cordial  greeting.  They  bespeak  your 
earnest  consideration  of  the  plans  and  purposes  of  the  American 


DERMATOLOGICAL   CONGRESS  27 

Medical  Association,  and  invite  your  encouragement  and  co- 
operation so  that  in  the  near  future  the  medical  profession 
of  the  world  shall  act  with  conspicuous  harmony  in  all  matters 
making  for  the  health,  the  contentment,  and  the  security  of 
the  people. 

And,  finally,  the  flight  of  my  allotted  time  for  this  occa- 
sion prompts  me  to  request  that  you  will  honor  us  again 
with  your  presence,  ever  remembering  to 

"Come  in  the  evening  or  come  in  the  morning; 
Come  when  you  are  looked  for  or  come  without  warning"; 

and  that  you  will  be  welcome. 

ADDRESS  BY  THE  PRESIDENT  OF  THE 
CONGRESS 

DR.  JAMES  C.  WHITE  : 

My  Colleagues  from  far  and  near: 

It  is  my  high  duty  and  privilege  to  greet  you  in  assembly,  to 
welcome  you  to  this  Sixth  International  Congress  of  Derma- 
tology, and  to  all  of  you,  my  countrymen  and  residents  of 
other  lands,  who  had  share  in  placing  me  in  this  most  honorable 
office,  to  offer  my  sincere  thanks. 

Many  of  you  are  passing  through  novel  experiences;  you 
have  been  living  on  the  vast  tracts  of  ocean,  and  have  learned 
how  small  a  part  of  the  world  are  the  spots  of  earth  you  call 
home.  You  have  come  to  a  new  and  younger  land  and  may 
be  expecting  to  find  much  that  is  strange  to  you.  If  you 
travel  far  over  our  vast  continent  you  will  indeed  see  a  great 
diversity  in  its  peoples,  immense  inland  seas,  rivers  which  in 
size  dwarf  your  own  to  brooks,  enormous  chains  of  towering 
mountain  peaks,  lofty  cataracts  and  deep  canons,  marvellous 
basins  and  geysers,  and  magnificent  forests  of  ancient  and 
gigantic  trees,  overtopping  even  our  heaven-aspiring,  Babel- 
like  edifices.  We  trust  you  will  visit  them  all.  But  in  your 
friends  and  colleagues  who  stand  here  on  the  edge  of  this  new 
world  to  meet  you  with  open  arms  and  warm  hearts,  and  who 
will  try  to  make  you  feel  that  this  magnificent  city  is  another 
home  to  you,  you  will  find  nothing  novel  or  strange.  We 
are  just  as  yourselves.  In  no  other  land  could  a  great  congress 


28  SIXTH    INTERNATIONAL 

be  held  where  visitors  would  find  so  close  a  tie  of  blood  kinship 
in  their  hosts. 

You  Germans  and  Austria-Hungarians  will  see  right  around 
you  more  of  your  race  than  in  almost  any  city  of  the  Father- 
land. You  from  Holland  will  find  in  this  town  they  founded 
representatives  of  your  oldest  and  purest  families  still.  You 
Latins  will  read  the  names  and  hear  the  tongues  which  will 
make  certain  districts  seem  as  if  you  were  at  home  again.  You 
Frenchmen  may  live  here  as  in  France,  eat  the  dishes  of  your 
best  chefs,  see  such  masterpieces  of  modern  French  art  as 
you  will  scarcely  find  at  home,  and  associate  with  the  best  old 
Gallic  stock  in  our  many  Huguenot  families,  and  in  one  of  our 
States,  founded  by  your  enterprising  ancestors,  your  old 
names,  your  old  customs  still  flourishing.  And  you  of  the 
North,  repeating  the  Viking's  earliest  voyage  to  the  West,  will 
find  in  our  central  regions  three  mighty  States,  called  New 
Scandinavia,  with  an  imported  but  dwindling  remnant  of  your 
old  enemy,  Lepra.  As  for  you  of  Great  Britain,  are  not  you 
and  we  mostly  of  one  and  the  same  motherhood  ?  Shakespeare 
and  Bacon,  Alfred  and  Elizabeth,  and  hosts  of  other  illustrious 
names  are  as  much  our  ancestors  and  those  of  our  near  and 
dear  sister  Canada  as  they  are  yours,  and  far  more  speak  here 
the  common  mother- tongue  than  on  your  own  soil. 

Here,  then,  and  in  the  American  part  of  this  Congress  you 
will  all  find  representatives  of  your  own  nationalities;  more- 
over, in  some  of  us  the  solution  of  that  interesting  question  in 
ethnology — What  is  the  outcome  of  a  mixture  of  these  leading 
races  of  mankind  ? 

And  no  doubt  some  of  you  have  been  wondering  on  your 
way  hither,  what  sort  of  physicians,  what  sort  of  derma- 
tologists, shall  we  find  in  these  men  of  the  Western  Continent  ? 
Some  of  you,  'tis  true,  have  met  some  of  us  in  Europe  and 
have,  no  doubt,  read  some  of  our  writings;  but  all  of  you 
do  not  know  all  of  us  in  this  way,  and  you  perhaps  do  not 
know  us  and  our  literature  as  well  or  as  generally  as  we  know 
you  and  yours.  It  is  one  of  the  most  important  functions 
of  this  international  league  to  promote  our  mutual  acquaint- 
ance. Now  there  are  no  great  differences  between  us,  you 
will  find.  I  have  just  alluded  to  the  identity  or  similarity  of 


DERMATOLOGICAL   CONGRESS  29 

stock.  How  has  professional  training  affected  it?  I  need  not 
speak  of  our  common  schools  or  of  the  academic  departments 
of  our  universities.  I  grant  that  yours  may  be  a  little  more 
thorough,  as  the  influences  of  ours  are  more  generally  diffused. 
The  period  of  required  professional  study  is  longer  with  you 
than  it  has  hitherto  been  with  us,  but  now  the  best  educated 
young  men  amongst  us  do  not  obtain  their  degree  of  Doctor  of 
Medicine  before  they  are  twenty-six  or  twenty-seven  years  old ; 
and  after  that  may  come  further  study  in  European  schools. 
We  may  all  alike  read  the  works  of  the  great  masters  in  medi- 
cine of  all  nations.  We  have  at  home  only  too  many  medical 
schools;  we  have  one  hundred  and  twenty-five  professors 
and  teachers  of  dermatology.  We  have  large  and  well  equipped 
special  laboratories  and  clinics,  perhaps  the  largest  and  most 
magnificent  medical  school  building  in  the  world,  and  we  have 
produced  some  admirable  and  exhaustive  treatises  and  count- 
less papers  on  dermatology.  Most  of  our  teachers  have  had 
the  advantage  of  studying  our  subject  with  the  most  distin- 
guished teachers  of  Europe,  living  and  dead.  You  see,  there- 
fore, that  you  should  find  us  very  much  the  same  as  yourselves, 
and  that  we  meet  as  equals,  alike  prepared  to  study  and  discuss 
the  questions  and  cases  which  shall  be  presented  for  our  con- 
sideration, and  equally  desirous  of  contributing  to  the  advance 
of  our  department  of  medicine.  In  one  point  we  may  indeed 
find  ourselves  your  inferiors :  in  our  efforts  to  repay  in  the  same 
measure  the  grand  hospitality  you  have  so  often  shown  us. 
But  this  failure  shall  not  come  from  any  lack  of  desire  or 
effort  on  our  part. 

Permit  me  to  offer  you  a  brief  sketch  of  some  of  the  changes 
which  have  taken  place  in  the  study  and  practice  of  dermatology 
under  the  observation  of  the  oldest  student  among  you  in  the 
last  half  century.  In  1856  and  1857  I  sat  in  the  clinic  of 
Ferdinand  Hebra  in  Vienna,  that  marvellous  training  school 
of  future  dermatologists.  I  took  with  me  to  Europe  a  clean 
slate,  for  at  that  time  no  instruction  in  skin  diseases  worth 
mentioning  was  given  in  America;  therefore,  that  terribly 
iconoclastic  feature  of  his  teaching  was  needless  for  his  trans- 
atlantic hearers.  It  seemed  to  me  then  that  this  ticket  admitted 
me  to  an  almost  perfect  system  of  object-lesson  instruction, 


30  SIXTH   INTERNATIONAL 

given  by  a  master  of  keenest  observation,  of  merciless  invective 
toward  the  schoolmen  of  the  past,  of  enthusiasm-inspiring 
earnestness.  No  one  could  fail  of  learning  a  great  deal  under 
such  teaching.  I  still  believe  it  deserved  and  still  deserves  the 
title  unparalleled.  We  were  taught  to  observe  closely  what  we 
saw,  and  to  waste  no  time  in  attempting  to  classify  the  result 
of  such  observation  under  undemonstrable  etiological  or 
pathological  theories;  moreover,  to  treat  lesions  by  remedies 
addressed  as  immediately  as  possible  to  them  and  not  to 
imaginary  causes.  Treatment,  therefore,  was  purely  empirical. 
We  did  try  to  look  a  little  below  the  surface  of  the  skin,  and  a 
limited  number  of  parasitic  affections  were  then  recognized. 
We  did  take  portions  of  diseased  cutaneous  tissue,  and  under 
Professor  Wedl's  directions  tease  them  out  into  shreds  under 
the  microscope.  We  had  not  then  arrived  at  the  knowledge  of 
infinitely  attenuated  section-cutting,  of  chemical  reactions 
beyond  the  solvent  power  of  potash,  or  of  the  innumerable, 
discriminating  stains  of  to-day.  No  wonder,  then,  that  we 
failed  to  recognize  the  all-present  foreign  organisms  beneath 
our  very  eyes.  At  that  period  the  school  of  Vienna  was  at  its 
highest  mark,  and  under  such  men  as  Skoda,  Rokitansky, 
Oppolzer,  Hyrtle,  and  Sigmund,  one  had  unsurpassed  advan- 
tages of  instruction  in  other  branches  of  medicine. 

Paris  was  then  beginning  to  lose  that  supremacy  she  had 
so  long  held  undisputed  as  Vienna  rose.  There  Hardy  was 
giving  excellent  instruction.  Bazin  was  possessed  by  his  over- 
mastering theories  of  dartrism  and  the  like,  and  Ricord  still 
reigned  as  the  unrivalled  teacher  in  syphilis.  Wilson,  with  his 
fluctuating  views  on  etiology  and  nomenclature,  was  the 
sole  authority  in  English-speaking  countries.  Simon  was  in 
Berlin;  Veiel,  Sen.,  in  Cannstatt;  Boeck,  Sen.,  in  Christiania; 
and  Fuchs  had  just  died  in  Gottingen.  These  were  our  worthy 
predecessors  in  dermatology  fifty  years  ago.  There  were  but 
few  professorships  and  clinics,  and  no  special  laboratories. 
The  literature  of  our  subject  was  scanty.  Hebra  had  as 
yet  published  no  book  but  his  surpassing  Atlas,  and  there 
were  no  journals  devoted  exclusively  to  the  interests  of  our 
department. 

In  America  dermatology  was   scarcely  recognized   as  a 


DERMATOLOGICAL   CONGRESS  3i 

specialty.  No  systematized  instruction  in  it  was  given  in 
any  school  of  medicine.  There  were  no  special  clinics  con- 
nected with  them,  and  in  our  hospitals  no  wards  for  the  treat- 
ment of  skin  diseases .  There  was  hardly  a  physician  exclusively 
engaged  in  the  practice  of  this  class  of  affections.  All  these 
opportunities  for  the  study  and  teaching  of  dermatology  had 
to  be  created.  It  has  been  a  long  and  hard  struggle  to  over- 
come the  opposition  on  the  part  of  the  general  profession,  the 
governing  boards  of  hospitals,  and  the  faculties  of  our  medical 
schools  to  the  position  of  dermatology  as  an  independent 
department  of  medicine.  One  obstacle  has  been  the  unfortu- 
nate fact  that  the  universities  had  no  hospitals  under  their 
control,  no  clinical  material  to  offer  their  appointees.  Then, 
too,  our  National  Government  has  no  share  in  the  direction 
either  of  universities  or  hospitals,  so  as  to  regulate  or  unify 
medical  education.  Therefore,  this  struggle  for  recognition 
on  the  part  of  your  colleagues  in  the  United  States  had  to  be 
made  single-handed  in  every  hospital  and  every  institution 
for  medical  education.  It  is  not  yet  quite  wholly  over,  but 
we  may  rejoice  in  great  advances.  Nearly  every  one  of  our 
one  hundred  and  sixty  or  more  schools  of  medicine  gives  special 
instruction  in  dermatology,  most  of  our  large  hospitals  make 
at  least  provision  for  out-patients  with  skin  diseases,  a  few 
of  them  have  wards  for  their  exclusive  care,  and  all  our 
cities  and  towns  of  magnitude  have  practitioners  of  this 
specialty.  We  have  a  National  Dermatological  Association, 
now  thirty  years  old  and  numbering  sixty  associates,  a  large 
Dermatological  Section  in  the  American  Medical  Association, 
and  many  of  our  most  important  cities  have  local  dermatologi- 
cal  clubs  or  societies,  all  of  whose  proceedings  are  published. 
Then,  too,  we  have  long  had  (under  various  titles)  an  American 
Journal  of  Cutaneous  Diseases.  There  have  been  published  also 
extensive  treatises,  cyclopedias,  atlases,  and  monographs  by 
American  workers.  You  see,  therefore,  that  we  do  not  stand 
so  far  below  the  standard  of  activity  you,  our  colleagues  from 
abroad  more  favored  in  opportunities,  have  set  for  us. 

The  attention  of  our  American  school  was  first  directed  to 
determine  what  difference  might  exist  between  dermatoses  here 
and  in  Europe — how  far,  that  is,  they  might  vary  on  account 


32  SIXTH   INTERNATIONAL 

of  diversities  in  climate,  racial  stock,  methods  of  living,  morals, 
dietaries,  etc.  For  this  purpose  a  careful  collection  of  statistics 
has  been  made  by  members  of  the  American  Dermatological 
Association  representing  observations  made  in  all  parts  of  the 
United  States  and  Canada.  The  number  of  cases  thus  collated 
amounts  to  more  than  half  a  million.  Their  value  is  exception- 
ally great  and  reliable,  because  they  are  founded  upon  the 
observation  of  trained  dermatologists.  A  study  of  them 
reveals  some  striking  features:  the  almost  complete  absence 
of  some  affections  common  in  Europe,  the  occurrence  here  of 
others  only  by  direct  importation,  a  variation  in  the  intensity 
of  certain  pathological  processes,  even  an  inclination  to  self- 
extinction  in  some  of  them,  and  the  existence  here  of  certain 
diseases  not  occurring  elsewhere.  In  recent  years  our  efforts 
have  been  especially  directed  to  the  foundation  of  laboratories 
devoted  to  research  into  the  essential  nature  of  skin  diseases. 
The  results  of  such  investigations  are  already  of  high  im- 
portance and  promise. 

The  recognition  of  the  importance  of  such  researches  has 
completely  changed  the  methods  of  teaching  dermatology 
amongst  us.  We  are  no  longer  content  with  those  of  our 
former  great  masters, — the  didactic  lectures  in  course,  a 
rapid  survey  of  the  whole  field  of  cutaneous  medicine,  with 
clinical  illustrations,  it  is  true,  but  scanned  mostly  afar,  and 
at  close  view  only  by  the  fortunate  holders  of  the  first  row 
of  seats  or  by  the  most  successful  rushers  of  the  crowd  around 
the  bedside.  The  medical  student  at  our  best  schools  takes  up 
its  study  after  two  or  three  years'  laboratory  drill  in  histology, 
biological  chemistry,  pathology,  bacteriology,  and  all  practical 
methods  of  microscopy.  He  comes  thus  prepared  to  apply 
this  knowledge  to  the  proper  understanding  of  the  wide  patho- 
logical panorama  which  skin  diseases  present.  He  makes  him- 
self familiar  with  their  clinical  features  by  sight,  by  touch,  in 
sections,  or  classes  of  a  few  members,  three  to  ten  only.  He 
sees  what  the  biopsy  reveals  of  anatomical  changes,  and  what 
bacteriological  researches  may  discover.  He  must  elucidate 
the  history  of  cases,  and  give  the  grounds  for  the  diagnoses 
he  must  present.  All  this  study  is  carried  on  in  the  immediate 
presence  of  the  instructor,  who  directs  and  criticises  at  every 


DERMATOLOGICAL   CONGRESS  33 

step  in  the  clinic  and  laboratory.  Such  is  the  individual 
system  of  teaching  dermatology  to-day  with  us.  For  graduate 
students  greater  facilities  are  furnished,  work  in  special  labora- 
tories, and  the  study  of  great  numbers  of  clinical  cases  for 
eight  hours  of  the  day  throughout  the  year  under  the  constant 
supervision  of  instructors.  Such  modern  methods  of  teaching 
cannot  fail  of  yielding  a  superior  product  to  those  of  our 
student  days. 

With  this  brief  sketch  of  the  evolution  of  dermatology  in 
North  America  during  a  half  century  we  may  well  note  the 
changes  which  the  same  period  has  brought  to  pass  in  our 
department  everywhere.  European  schools  have  risen  and 
declined  in  popularity  with  the  coming  and  passing  of  cele- 
brated teachers.  The  days  of  narrowing  theories  and  school- 
men have  gone  forever,  let  us  hope.  In  their  place  we  have  the 
marvellous  revelations  of  modern  chemistry,  physics,  and  the 
microscope,  tangible  data  for  the  basis  of  our  etiology  and  path- 
ology. We  may  now  credibly  predict  what  we  are  about  to 
discover  in  both  these  directions  when  our  knowledge  of  meth- 
ods shall  have  advanced  a  little  farther.  We  see  no  bounds 
to  the  extent  of  such  discovery.  In  an  address  delivered 
thirty  years  ago  I  ventured  to  predict  that  I  should  live  to  be- 
hold with  my  eyes  the  cause  of  pulmonary  tuberculosis ;  of  its 
cutaneous  forms  we  had  then  no  suspicion.  We  now  look 
backwards  upon  this  memorable  event.  When  our  great 
master  of  cellular  pathology  was  giving  some  of  you  his 
inspiring  instruction,  who  thought  that  he  might  some  day 
come  to  distant  and  primitive  America  to  see  upon  a  screen, 
simultaneously  with  a  thousand  other  observers,  the  image 
of  a  cell  a  foot  in  diameter  filled  with  visible  organisms  of  that 
scourge  of  mankind,  variola?  Even  our  trained  imagination 
cannot  bear  us  forward  to  the  limit  of  such  revelation. 

When  I  began  the  study  of  skin  diseases  under  Professor 
Hebra  there  were  upon  his  tabular  list  of  diseases  less  than 
one  hundred  titles.  Since  then  closer  clinical  observation, 
advanced  knowledge  of  their  anatomical  nature,  recent  investi- 
gations into  their  etiological  relations  have  individualized  and 
multiplied  them  until  they  now  number  more  than  two  hundred. 
At  the  first  meeting  of  this  International  Congress  in  Paris, 

VOL.   I. — 3 


34  SIXTH   INTERNATIONAL 

in  1889,  a  previously  unnoticed  disease,  discovered  simultane- 
ously and  independently  in  France  and  America,  was  first 
brought  to  your  attention.  Now  we  are  able  to  show  other 
dermatoses  with  which  some  of  you  are  unacquainted. 

Perhaps  a  word  of  caution  regarding  the  unnecessary- 
division  of  diseases  and  multiplication  of  titles  may  not  be 
out  of  place  here.  It  seems  to  me  that  some  of  us  are  over- 
inclined  to  magnify  the  significance  of  slight  clinical  variations, 
to  attribute  to  them  specific  importance,  and  to  emphasize 
their  pseudo-independence  by  bestowing  upon  them  titles 
of  individuality.  In  my  opinion  we  should  not  change  well 
established  landmarks  except  for  reasons  founded  on  demon- 
strable differences  in  anatomy  or  etiology.  Then,  too,  the 
character  of  modern  titles  has  become  a  matter  worthy  our 
serious  consideration.  It  has  become  too  complex  and  cum- 
bersome, as  has  the  nomenclature  of  other  departments  of 
natural  science.  There  was  a  time  when  naturalists  were 
content  with  simple  generic  and  specific  names;  now  every 
flower  or  bird  must  have  at  least  three  or  four  individual  titles 
bestowed  upon  it.  Are  we  not  in  danger  of  exceeding  even 
this  redundancy?  There  is  evident  a  disposition  to  avoid 
such  profuse  and  exhaustively  descriptive  nomenclature 
by  calling  a  newly  established  dermatosis  by  the  name  of  its 
sponsor,  as  Bazin's  disease,  Kaposi's  disease,  etc.  Some  fifty 
of  such  titles  might  be  enumerated.  This  is  an  entirely  arbi- 
trary system  of  designating  a  disease,  suggesting  nothing 
descriptive  of  its  nature,  or  its  proper  position  in  any  plan  of 
scientific  classification.  If  it  continue,  a  pocket  glossary  will 
soon  become  necessary  to  every  reader  of  our  literature,  unless 
blessed  with  an  exceptional  memory.  Such  titles,  like  those 
geographical  names  given  to  affections  of  remote  regions,  may 
be  admissible  until  the  nature  of  the  disease  be  fully  elucidated ; 
then  they  should  be  properly  christened  and  registered.  It 
should  be  one  of  the  most  important  functions  of  this  inter- 
national body  to  prepare  and  officially  adopt  some  satisfactory 
system  of  classification  and  nomenclature,  to  which  we  should 
adhere  for  the  common  good.  I  believe  the  creation  of  a 
standing  committee  of  this  association  to  consider  the  subject 
n  a  broad  way,  on  which  should  be  representatives  of  all  our 


DERMATOLOGICAL   CONGRESS  35 

great  nations,  unprejudiced  by  past  systems  of  schools  or 
individuals,  would  result  in  vast  advantage  to  dermatology. 
The  establishment  of  such  an  international  code  should  not  be 
an  impossibility.  Let  us  undertake  it. 

And  are  there  not  other  matters  coming  within  the  bounds  of 
our  field  of  medicine,  which  we,  as  the  most  competent  body 
in  existence,  should  take  a  more  prominent  part  in  than  hereto- 
fore? Should  we  not  feel  it  incumbent  upon  us  to  assume  a 
more  advisory  and  executive  position  in  relation  to  sanitary 
questions  of  international  interest,  rather  than  the  merely 
academic  one  we  have  hitherto  occupied?  Had  we  conscien- 
tiously interpreted  our  highest  functions  in  this  direction,  it 
would  scarcely  have  been  necessary  to  found  a  special  inter- 
national congress  for  the  study  and  control  of  leprosy,  of 
syphilis,  and  of  cutaneous  tuberculosis.  But  even  if  we  have 
allowed  our  sphere  of  usefulness  to  be  thus  curtailed,  there  yet 
remain  many  important  questions  for  us  to  act  upon.  I  will 
mention  some  of  them : 

1.  What  are  the  influences  of  race,  geographical  conditions, 
climate,  national  customs,  etc.,  upon  the  evolution  and  type 
of  diseases  of  the  skin? 

2.  What  variations  does  emigration  induce  in  dermatoses? 

3.  What  cutaneous  affections  should  national  governments 
regard  as  infective,   and  seek  to  control  by  restriction  of 
immigration,  by  enforced  insulation,  and  similar  measures? 

4.  How  far  is  it  practicable  and  incumbent  upon  national 
governments  to  control  the  continuance  and  prevalence  of 
hereditary  dermatoses  by  restriction  upon  marriage  laws? 

5.  Should  not  the  influence  of  this  body  be  directed  to 
induce  governments  to  aid  in  the  support  of  researches  bearing 
upon  sanitary  questions  of  international  importance? 

We  must  all  alike  be  greatly  interested  in  the  investigations 
which  have  been  recently  carried  on  by  our  colleagues  in  certain 
tropical  regions  which  are  of  vast  importance  to  dermatology 
and  general  medicine.  We  are  fortunate  in  having  before  us 
the  great  privilege  of  hearing  the  results  of  their  researches 
directly  from  some  of  the  most  eminent  of  them.  Primarily 
these  studies  have  been  undertaken  so  far  from  the  usual 
centres  of  such  research,  because  there  only  could  be  found 


36  SIXTH   INTERNATIONAL 

available  in  sufficient  abundance  the  requisite  material 
Fortunately,  we  are  not  yet  differentiated  so  widely  from  our 
simian  relatives  in  the  physical  character  of  our  tissues,  that 
we  do  not  possess  in  common  the  susceptibility  to  the  invasion 
of  certain  morbific  agencies,  which  are  the  cause  of  some  of  our 
most  disastrous  diseases.  As  their  serious  nature  inhibits  the 
application  of  the  ordinary  methods  of  experimentation  to  our 
fellow  men,  it  is  indeed  fortunate  that  we  may  legitimately 
use  these  lowly  brethren  for  such  purposes. 

With  the  important  studies  concerning  the  nature  of  the 
variolous  affections  made  at  the  same  time  in  Manila  by  Drs. 
Brinckerhoff  and  Tyzzer  you  are  acquainted.  (Their  results  are 
published  in  the  Journal  of  Medical  Research,  January,  1906, 
under  the  title :  ' '  Studies  upon  Experimental  Variola  and  Vac- 
cinia in  Quadrumana.")  I  am  happy  to  announce  that  Dr. 
Brinckerhoff  has  accepted  the  appointment  from  our  National 
Government  of  medical  director  of  the  establishment  for  the 
care  of  lepers  in  the  Hawaiian  Islands,  and  will  devote  himself 
for  five  or  ten  years  in  the  laboratory  he  has  established  on 
Molokai  to  the  study  of  this  disease.  These  researches,  un- 
restricted in  scope,  conducted  by  so  accomplished  an  investi- 
gator, are  of  great  promise. 

And  there  are  not  a  few  other  affections  of  close  interest 
to  us  of  which  we  see  only  an  occasional  immigrant  example, 
which  can  be  properly  studied  only  in  their  tropical  home, 
and  should  be  there  studied  by  experienced  dermatologists. 
It  is  evident  that  such  researches  cannot  be  carried  on  at  the 
personal  expense  of  such  investigators,  or  by  any  one  national 
government  on  a  sufficiently  comprehensive  basis.  It  can  be 
accomplished  only  by  the  combined  efforts  of  the  medical 
profession  of  all  nations.  Now,  fortunately,  we  have  in  this 
association  just  the  right  body  to  carry  out  this  all-important 
work.  Such  an  undertaking  on  our  part  should  be  regarded 
as  one  of  our  most  appropriate  and  essential  functions.  A 
large  fund  should  be  raised,  and  the  aid  of  our  respective 
governments  should  be  solicited  in  behalf  of  the  plan.  An 
international  committee,  composed  partly  of  members  of  this 
body,  partly  of  well-known  authorities  on  tropical  diseases  in 
all  parts  of  the  world,  might  be  established  under  our  adminis- 


DERMATOLOGICAL   CONGRESS  37 

tration,  which  should  raise  the  means  for  and  superintend 
such  investigations.  Think  of  the  vast  benefit  to  medical 
science  if  we  could  send  out  properly  trained  investigators  to 
any  regions  where  questions  of  great  interest  and  grave  inter- 
national importance  demanded  solution.  May  I  suggest  that 
a  committee  be  appointed  at  this  meeting* to  consider  the 
subject  and  to  report  before  the  adjournment  of  the  Congress? 

Looking  backwards  over  my  fifty  years  of  study  and  prac- 
tice in  affections  of  the  skin  I  am  led  to  ask  myself :  What  are 
the  most  prominent  marks  of  progress  I  have  observed,  and 
what  the  present  signs  of  promise  are? 

I  recognize  three  distinct  eras  of  advance: 

1.  In   place    of  the    artificial    systems    of    classification 
based  on  such  narrow  lines  as  similarities  in  external  mani- 
festations,  especially  in   the   so-called    "primary   lesion,"   a 
superstitious  belief  in  the  existence  of  purely  imaginary  in- 
fluences or  diatheses  as  a  foundation  of  etiology,  and  a  survival 
of  the  old  doctrines  that  all  dermatoses  are  necessarily  merely 
surface  expressions  of  internal  systemic  disorders,  and  that  the 
cutaneous  tissues  are  denied  the  possibility  of  independent 
pathological  modification;  in  place  of  such  an  unscientific 
status  as  then  prevailed  there  came  about,  largely  through  the 
powerful  teaching  of  a  great  master,  a  proper  appreciation  of 
the  meaning  of  external  manifestations  and  a  regrouping  of  the 
mutual  relations  of  individual  affections,  the  recognition  of  the 
pathological  independence  of  cutaneous  changes,  and  a  health- 
ful skepticism  with  regard  to  undemonstrable  creeds ;  a  school 
based  on  purely  clinical  data  was  inaugurated,  an  immense  step 
upwards,  an  emergence  above  the  clouds  of  superstition  and 
fetishism. 

2.  Under  the  analytical  spirit  infused  into  all  departments 
of  medicine  by  Virchow,   students  in  dermatology  did  not 
long  remain  satisfied  with  the  old  methods  of  studying  the 
anatomical  changes  which  underlie  the  surface  expressions 
of  cutaneous  disease,    but  with   the  resources  of  improved 
technique  carried  their  researches  into  the  minutest  details 
of  tissue  modification.     Thus  was  built  up  a  knowledge  of 
cutaneous  pathology,  by  which  some  sort  of  scientific  classi- 
fication became  possible.     It  was  one  of  anatomical  affinity, 


38  SIXTH   INTERNATIONAL 

of  identity  of  structure  in  the  place  of  one  founded  on  merely 
external  resemblances.  This  was,  indeed,  a  great  advance, 
but  far  from  satisfactory.  It  might  show  that  the  tissue 
changes  in  lupus  and  leprosy,  for  instance,  closely  resembled 
each  other,  but  not  why  they  clinically  were  so  far  apart.  It 
gave  not  the  slightest  clew  to  their  etiological  relations. 

3.  There  was  revealed  to  one  or  two  patient  investigators 
through  advanced  methods  of  technique  the  presence  in  the 
tissues  of  these  two  most  important  diseases  of  foreign  organ- 
isms, which  explained  all  the  phenomena  we  had  been  so 
blindly  observing.  This  was  the  key  to  the  secret  of  causation 
which  had  so  long  baffled  us.  I  need  not  dwell  upon  the  all- 
importance  of  this  discovery,  and  the  constantly  increasing 
development  in  methods  of  research  to  which  it  has  led.  It  has 
already  taught  us  a  vast  deal  as  to  the  real  nature  of  cutaneous 
disease,  the  means  of  controlling  some  of  the  most  dangerous 
forms  of  pestilence,  and  given  us  the  hope  of  solving  the  mys- 
tery of  much  or  all  that  yet  remains  unrevealed  to  us. 

These,  then,  are  the  three  eras  of  advance  within  my 
experience : 

1.  The  knowledge  founded  on  a  more  careful  study  of  the 
external  manifestations  and  unbiased  interpretation  of  clinical 
phenomena. 

2.  A  deeper  knowledge  of  the  minute  anatomy  of  tissue 
changes  in,  and  a  more  scientific  grouping  of,  dermatoses. 

3.  The  recognition  of  the  real  nature  and  cause  of  visible 
lesions  and  underlying  tissue   changes  and  the  essence   of 
disease, — a  true  system  of  pathology, — the  promise  of  attain- 
ment of  the  power  of  prevention,  of  establishing  immunity, 
of  founding  a  broader  system  of  rational  therapeutics. 

And  how  shall  we  interpret  the  action  of  the  micro-organisms 
which  have  been  found  in  so  many  cutaneous  diseases,  or  which 
our  justifiable  convictions  forestall  the  revelation  of  their 
existence  in  others,  to  such  an  extent  that  the  remainder  will 
be  the  exception  to  such  etiological  relations?  The  effects  of 
parasitism  on  the  cutaneous  tissues  of  our  earlier  experience 
were  purely  local  and  simply  inflammatory  in  character.  The 
trauma  of  animal  parasites  produced  a  slight  degree  of  super- 
ficial dermatitis  of  the  immediate  surrounding  area,  sometimes 


DERMATOLOGICAL   CONGRESS  39 

followed  by  widespread  secondary  disturbances  in  consequence 
of  the  pruritus  thus  excited  and  subsequent  scratching.  The 
then  known  parasitic  flora  excited  also  purely  local  changes 
in  the  skin  and  appendages  of  unimportant  nature.  Neither 
animal  nor  vegetable  forms  gave  rise  to  any  constitutional 
disturbance,  or  endangered  life. 

Then  came  the  demonstration  of  the  existence  of  other 
forms  of  parasitic  organisms  in  the  tissues  of  far  more  serious 
diseases,  the  etiological  relations  of  which  have  been  established 
on  irrefragable  evidence.  The  tissue  changes  produced  by 
their  presence,  both  local  and  remote,  and  their  influence  upon 
their  host  are  of  the  gravest  character,  some  of  them  in  fact 
being  the  cause  of  the  greatest  mortality  in  mankind  and  other 
animals  within  historic  times.  How  can  we  account  for  such 
deadly  influences  inherent  in  such  infinitely  minute  organisms, 
or  for  the  striking  differences  in  the  nature  of  the  manifesta- 
tions they  give  rise  to,  in  their  periods  of  incubation,  the 
diversity  of  tissue  changes  they  cause,  their  variations  in 
course  from  a  few  days  to  many  years?  Here  are  two  so-called 
bacilli  of  minute  size,  so  like  in  appearance  and  reaction  under 
known  reagents  that  they  can  scarcely  be  distinguished  by 
the  most  experienced  observers,  yet  just  as  the  human  ovule 
or  the  plant  germ  carries  with  it  the  inherent  capability  of 
building  up  from  the  material  furnished  it  the  stately  tree 
with  its  century  changes,  or  the  heroic  future  of  a  man,  so  does 
the  micro-organism  of  lepra  bear  within  its  simple  and  insig- 
nificant form  the  power  of  transforming  human  tissues  into 
the  fell  shape  we  know ;  and  so  does  the  other  possess  the  unde- 
veloped power  of  causing  the  cutaneous  tissues  to  express  the 
influence  of  its  presence  in  quite  different  objective  forms,  and 
of  adding  countless  victims  to  the  "great  white  plague." 
Some  of  them,  too,  have  a  mysterious  power  of  protection,  of 
bestowing  immunization  upon  their  human  host. 

How  shall  we,  I  repeat,  explain  such  manifold  and  far- 
reaching  powers?  Can  they  be  mechanical,  in  part,  at  least? 
When  we  consider  the  effect  of  the  smallest  particle  of  foreign 
inert  matter  upon  human  tissues  at  times,  the  "spec"  in  the 
eye  for  instance,  we  cannot  deny  the  possibility  of  such  sort 
of  action,  in  some  measure,  at  least.  Can  they  be  chemical 


40  SIXTH   INTERNATIONAL 

in  nature?  We  have  only  to  recall  the  influence  of  organisms 
but  slightly  higher  in  the  scale  of  vegetable  life,  in  producing 
new  and  beneficial  modifications  in  organic  compounds, — 
the  alcoholic  and  acetous  fermentations,  for  example ;  or  of  the 
most  disastrous  nature,  as  some  of  the  oidia.  We  may  feel 
assured  that  they,  too,  may  possess  the  inherent  property  of 
generating  products  too  subtle  to  be  recognized  by  our  limited 
analytical  agents,  and  well  capable  of  producing  all  grades  of 
tissue  change  in  their  immediate  presence,  as  well  as  those 
which  express  themselves  in  other  ways  throughout  the  whole 
economy;  or  is  there  some  other  subtler  form  of  influence  at 
work,  the  nature  of  which  is  wholly  unrevealed? 

To  such  remotely  manifested  influences  we  give  the  name 
toxins,  a  well  chosen  title,  perhaps,  but  bearing  in  itself  no 
interpretation  of  their  nature.  To  such  mysterious  powers 
we  may  attribute  the  prodromal  and  evanescent  cutaneous 
manifestations  in  lepra,  and  the  long-delayed  surface  lesions 
in  tuberculosis  we  call  tuberculides.  In  the  solution  of  this 
grave  question — the  nature  of  the  action  of  such  micro- 
organisms upon  human  tissues — we  have  before  us  an  un- 
trodden field  of  research.  The  satisfactory  answer  may  be 
surely  expected,  for  there  is  no  secret  of  nature  which  human 
intelligence  may  not  eventually  comprehend. 

THE    RESULTS    OF    OUR    KNOWLEDGE    OF    MODERN    CUTANEOUS 
PATHOLOGY  ON  PRACTICAL  THERAPEUTICS 

Is  it  not  lamentable  to  confess  how  loitering  has  been  the 
advance  in  practical  therapeutics  upon  our  recent  progress 
in  the  knowledge  of  cutaneous  pathology?  We  are  wellnigh 
as  helpless  in  the  control  of  our  gravest  as  well  as  of  our  most 
common  dermatoses  as  we  were  half  a  century  ago,  and  our 
most  successful  therapeutical  measures  are  as  empirical  in 
nature  as  they  have  ever  been.  A  few  until  recently  un- 
recognized physical  agencies  have  been  employed,  working 
some  good,  and  evil  as  well,  but  we  are  learning  that  their 
beneficent  powers  have  narrow  limitations.  We  have  recog- 
nized the  parasitological  nature  of  more  and  more  affections, 
but  our  parasiticides  can  control  only  the  most  superficial 
of  them. 


DERMATOLOGICAL   CONGRESS  41 

So  far,  our  researches  in  the  portentous  realms  of  immuniza- 
tion have  not  brought  forth  such  practical  results  as  did  the 
shrewd,  unaided  observations  of  that  old  English  country 
physician,  Jenner.  Can  we  predict  with  certainty  the  cura- 
tive results  of  our  prescriptions  in  any  individual  case  of 
eczema,  or  psoriasis,  or  lichen,  or  acne,  or  the  other  common 
dermatoses  which  fill  our  daily  clinics,  results  which  convert 
our  most  confiding  private  patients  into  doubters  of  our  skill, 
and  give  encouragement  to  the  ingenious  efforts  of  the  nostrum 
manufacturers?  Have  we  any  power  over  the  pigment  pro- 
ducing layer  of  the  cuticle?  Can  we  control  the  disordered 
actions  of  the  sweat  glands  ?  Who  claims  ability  to  cure  lupus 
erythematosus,  not  the  one  case,  but  every  case?  Have  we 
a  surer  power  over  the  deeper  and  graver  forms  of  cutaneous 
disease  than  the  surgeon's  hand  of  fifty  years  ago? 

Now  I  am  not  a  pessimist  in  therapeutics.  I  know  that 
the  skilled  dermatologist  does  a  vast  amount  of  good  in  the 
relief  of  human  suffering,  and  is  fully  as  successful  in  dealing 
with  disease  as  physicians  in  other  fields  of  practice.  Un- 
fortunately for  us  the  immediate  results  of  treatment  are 
always  in  view.  Still  I  believe  in  an  honest  recognition  of  our 
present  limitations  as  one  of  the  steps  towards  securing  greater 
powers  of  control  in  the  future.  I  look  forward  with  assurance 
to  the  slow  coming  of  successful  and  rational  methods  of  cure, 
of  which  a  few  happy  glimpses  have  appeared. 

PROGRESS 

Even  since  the  last  meeting  of  this  Congress  in  Berlin  there 
has  been  a  noteworthy  progress  in  dermatology,  especially  in 
research  work.  The  great  activity  and  general  interest  in 
this  direction  are  shown  by  examination  of  the  current  litera- 
ture in  connection  with  a  single  question.  The  discovery 
of  spirochaeta  pallida,  its  etiological  relations  to  syphilis,  and  its 
revolutionary  bearings  upon  the  pathology  of  this  disease, 
have  stimulated  the  production  of  several  hundred  articles 
from  observers  in  all  parts  of  the  world.  The  transference 
also  of  the  field  of  investigation  in  this  and  kindred  diseases 
from  man  to  his  nearest  relatives  in  the  animal  creation  has 


42  SIXTH   INTERNATIONAL 

led  to  surprising  and  most  important  results.  Your  Com- 
mittee of  Organization  has  selected,  therefore,  as  themes  for 
special  consideration  such  subjects  as  will  enable  distinguished 
workers  in  these  fields  of  research  to  present  to  you  the 
results  of  their  latest  investigations  and  conclusions. 

You  are  all  familiar  with  the  self-sacrificing  spirit  in  which 
our  distinguished  colleague,  Professor  Neisser,  has  devoted 
himself — time,  revenue,  comfort — to  the  study  of  this  most 
important  subject,  syphilis.  How  he  transferred  the  field  of 
his  investigations  from  his  clinic  and  observations  upon  human 
patients  to  the  distant  tropics  and  the  home  of  the  higher  apes. 
You  know  the  invaluable  results  of  the  experiments  there  made. 
You  have  read  also  in  his  recent  report  to  the  German  Govern- 
ment the  details  of  this  work.  He  was  to  have  been  with  us 
on  this  occasion  to  present  his  latest  conclusions  from  the 
results  thus  obtained,  but  alas!  in  obedience  to  the  call  of 
that  government,  which  has  generously  appropriated  100,000 
marks  for  the  continuation  of  these  investigations,  he  has 
again  banished  himself,  with  his  devoted  wife  as  co-laborer,  to 
the  Orient,  and  sends  us  a  message  of  his  regret  that  he  cannot 
be  present  with  us.  What  an  example  of  clinical  experimenta- 
tion on  a  grand  scale,  of  noble  devotion  to  science  and  humanity ! 
Will  you,  his  colleagues  from  all  parts  of  the  world,  join  in 
sending  him  our  best  congratulations  upon  his  continued  good 
health,  and  a  sincere  expression  of  our  high  appreciation  of 
his  all-important  labors? 

And  I  would  say  a  word,  too,  for  those  dumb  relatives  of 
ours,  the  anthropoid  apes,  who  show  their  near  affinity  to  us  by 
their  susceptibility  to  this  great  curse  of  mankind.  Would 
they  could  comprehend  our  grateful  appreciation  of  their 
passive  sacrifices  for  humanity! 

And  I  cannot  close  this  brief  account  of  most  recent  progress 
without  alluding  to  another  therapeutic  agency  evolved  from 
research  work  in  the  field  of  micro-parasitology,  the  protective 
and  curative  influence  of  the  introduction  of  the  modified 
essence  of  disease-producing  germs  within  the  economy,  which 
we  call  opsonism.  This  subject  will  also  be  presented  by 
competent  observers. 

In  the  face  of  such  surprising  results  of  research  in  the 


DERMATOLOG1CAL   CONGRESS  43 

past  few  years,  how  inadequately  can  the  keenest  imagination 
foretell  the  possible  progress  of  the  coming  decade! 

The  marked  increase  in  the  number  of  dermatological 
societies  in  all  civilized  countries,  some  twenty  or  more  existing 
at  present,  and  the  twenty  to  thirty  journals  devoted  exclu- 
sively to  the  literature  of  our  specialty  bear  witness  also  to  the 
progressive  interest  shown  in  dermatology,  so  that  it  has  be- 
come wellnigh  impossible  to  keep  in  touch  with  such  a  record. 
You  may  be  surprised  also  to  learn  that  the  number  of  invita- 
tions to  attend  this  Congress,  sent  only  to  those  especially 
interested  in  our  department  of  medicine,  is  twenty-five 
hundred. 

NECROLOGY 

But,  alas!  it  is  my  sad  duty  to  make  brief  mention  of  those 
who  have  hitherto  worked  with  us,  and  who  have  left  us 
forever  since  our  last  meeting: 

Neumann,  Barthelemy,  Tarnowsky,  Haslund,  Du  Castel, 
Mauriac,  Finsen,  Schaudinn,  Atkinson,  Greenough,  Allen,  Dron. 

Some  of  them  were  among  our  most  distinguished  colleagues, 
who  had  labored  long  and  nobly  for  science  and  humanity; 
others  were  only  at  the  beginning  of  their  brilliant  career, 
already  illuminated  by  splendid  achievements — one  of  them, 
Allen,  a  lamented  member  of  your  Organization  Committee. 
During  my  professional  life  some  forty  conspicuous  colleagues 
in  our  specialty,  some  of  them  the  great  masters,  have  died. 
May  I  ask  you  to  rise  for  a  moment  in  respect  to  their  memory? 

CONCLUSION 

And  now  in  closing  I  invite  your  attention  to  the  full  and 
inviting  programme  which  the  Organization  Committee  has  pre- 
pared and  placed  in  your  hands.  They  have  solicited  contribu- 
tions upon  the  most  important  subjects  from  distinguished 
dermatologists  of  all  countries,  and  if  we  have  not  met  with 
that  degree  of  generous  response  from  our  foreign  colleagues 
we  expected,  we  hope  with  the  aid  of  those  who  honor  us  with 
their  presence  to  make  the  Congress  a  success. 

Adjournment  at  i  p.  m. 


AFTERNOON  SESSION  —  3  P.  M. 

DR.  EDWARD  L.  KEYES,  of  New  York,  Vice-President,  in 
the  chair. 

PROPOSALS  FOR  DIMINISHING  THE  DIFFUSION 

OF  LEPROSY 

BY  PROF.  ROBERT  CAMPANA,  OF  ROME 


Considerations  regarding  the  nature  and  special  symptoms 
of  leprosy  lead  to  the  conclusion  that  a  mutual  understanding 
should  be  arrived  at  amongst  civilized  nations  concerning 
the  treatment  of  this  disease  and  its  aspects  as  an  evil  which 
affects  the  individual  and  society. 

Local  treatment  is  necessary  in  leprosy  in  the  initial  stages 
of  macular  and  tubercular  symptoms.  These  can  be  arrested 
by  radical  surgical  treatment,  followed  up  by  cauterization. 
The  most  rigorous  aseptic  and  antiseptic  treatment  of  the 
ever-varying  lesions  is  indispensable,  according  to  the  man- 
ner in  which  they  are  developed  in  the  patients,  and  this  is  es- 
pecially the  case  in  the  later  stages  of  the  disease. 

Tubercular  leprosy  is  a  purely  local  disease  of  much  gravity, 
and  its  contagiousness,  which  has  been  proved  experimentally, 
is  in  direct  proportion  to  the  shortness  of  the  time  that  malady 
has  lasted.  Hence  the  radical  treatment  of  the  disease  is  to 
destroy  its  manifestations  as  soon  as  they  appear.  The 
severe  mutilations  and  the  grave  febrile  and  phthisical  phe- 
nomena which  may  occur  in  leprosy  are  the  consequences 
of  septic  conditions  caused  by  ulceration  and  trophic  changes. 
Hence  the  treatment  of  patients  in  whom  these  lesions  have 
occurred  ought  to  be  directed  towards  diminishing  the  in- 
jurious effects  of  these  trophic  changes,  those  of  the  joints 
more  particularly,  to  prevent  breaches  of  surface,  and  to  arrest 

44 


SIXTH  INTERNAT.  DERMATOL.    CONGRESS  45 

the  continuance  of  sources  of  sepsis  in  the  individual  patients 
and  in  their  houses  and  in  leper  asylums.  When  the  phenom- 
ena of  sepsis  have  occurred,  the  suitable  treatment  is  to  attack 
them  courageously,  studying  when  possible  the  special  nature 
of  the  various  sources  of  sepsis,  and  in  abating  them  to  bear 
in  mind  the  unusual  conditions  of  the  patients  in  whom  they 
have  developed. 

The  bacillus  lepras,  dead  or  alive,  remains  in  the  tissues 
for  a  long  time.  Its  presence  is  more  easily  demonstrated 
in  the  initial  period  of  tubercular  leprosy  than  in  the  advanced 
stages  or  during  the  period  of  resolution.  Very  often  the 
organism  is  absent,  owing  to  the  spontaneous  exhaustion  of 
the  infection,  though  macroscopic  evidences  of  the  disease 
may  still  persist  in  the  skin  and  other  organs  affected. 

Discussion 

DR.  DOUGLASS  W.  MONTGOMERY,  of  San  Francisco,  said  he  did 
not  understand  Prof.  Campana's  point  of  view  that  a  patient, 
when  once  discovered  to  have  leprosy,  is  no  more  a  menace  to 
society.  As  a  matter  of  fact,  it  is  frequently  difficult  to  establish 
the  source  of  infection,  and  personally  he  could  recall  but  a  single 
instance  where  he  was  able  to  do  it.  The  patient  was  a  woman 
who  was  born  in  Ireland,  and  who  had  resided  in  New  York  before 
going  to  San  Francisco.  She  was  a  well-marked  leper,  although 
her  children  and  husband  were  free  from  that  disease.  Investi- 
gation showed  that  this  woman  had  harbored  in  her  home  a  well- 
marked  leper  from  Hawaii,  and  he  had  no  doubt  that  this  Irish 
woman  had  contracted  her  leprosy  from  that  man,  as  he  had 
lived  in  the  same  house  for  quite  a  long  time.  The  case  was  one 
of  tubercular  leprosy  in  full  bloom,  so  that  he  thought  this  case 
showed  conclusively  that  Prof.  Campana's  view,  that  a  patient 
when  once  discovered  to  have  leprosy  is  no  more  a  menace  to  so- 
ciety, is  incorrect. 

Dr.  Montgomery  said  that,  so  far  as  the  first  evidences  of  leprosy 
are  concerned,  the  physician  rarely  sees  them.  He  could  recall 
only  a  few  instances  where  he  was  able  to  observe  and  follow  the 
early  erythematous  patches  of  the  disease,  but  such  instances  are 
rare.  The  early  symptoms  are  such  that  the  patient  himself  does 
not  usually  attach  much  importance  to  them,  and  it  is  only  later, 
when  the  disease  is  well  established,  that  medical  advice  is  sought. 


46  SIXTH   INTERNATIONAL 

A  long  period  frequently  elapses  between  the  initial  symptoms  of 
leprosy  and  a  well-marked  case  of  lepra. 

DR.  H.  E.  MENAGE,  of  New  Orleans,  said  that  in  the  majority 
of  cases  of  leprosy,  the  micro-organism  was  either  not  demonstrable 
or  had  lost  its  virulence  in  the  trophic  lesions.  He  recalled  cases, 
however,  that  had  apparently  originated  from  late  lesions  of  tuber- 
cular leprosy,  and  he  had  seen  cases  develop  side  by  side  during 
the  active  stage  of  tubercular  leprosy. 

DR.  WALTER  REMSEN  BRINCKERHOFF,  of  Honolulu,  said  the 
question  of  the  diffusion  of  leprosy  was  a  public  health  problem 
of  great  interest. 

In  Hawaii  the  disease  had  been  under  control  for  over  forty 
years  by  means  of  segregation.  In  watching  the  methods  by  which 
this  had  been  brought  about,  he  had  been  struck  by  the  extreme 
difficulty  that  had  been  encountered  in  persuading  lepers  to  go 
into  segregation.  For  that  reason,  he  thought  it  important  to 
emphasize  the  fact,  among  people  who  were  liable  to  contract  the 
disease,  that  treatment  could  be  carried  out  in  the  segregation 
colonies  which,  while  not  necessarily  holding  out  the  hope  of  a 
cure,  would  at  least  afford  a  great  amelioration  of  symptoms. 
The  popular  conception  was  that  when  a  patient  once  entered  a 
leprosarium,  it  was  to  die  without  treatment;  this  caused  much 
prejudice  against  these  institutions.  In  communities  where  lep- 
rosy was  likely  to  occur,  the  people  should  be  informed  that 
proper  treatment  would  render  them  more  comfortable,  even  if  it 
will  not  cure  them.  In  this  way  only  would  it  be  possible  to  get 
control  of  the  cases  early  in  the  disease. 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  asked  Prof.  Campana  whether 
he  had  said  that  bacilli  were  not  to  be  found  in  the  tubercular 
lesions  of  leprosy,  or  whether  he  referred  to  the  late  dystrophic 
lesions. 

PROF.  CAMPANA  replied  that  the  bacilli  were  found  in  the  early 
lesions,  but  not  after  the  disease  had  attained  its  full  bloom.  The 
infectious  character  of  the  disease  gradually  diminished  and  finally 
disappeared  entirely. 

DR.  ISADORE  DYER,  of  New  Orleans,  said  it  was  unfortunate  that 
one  had  to  discuss  a  paper,  which  was  apparently  of  so  much 
interest,  second-hand,  and  personally  he  had  not  intended  to  dis- 
cuss it  until  Dr.  Grindon  brought  out  the  point  in  regard  to  the 


DERMATOLOGICAL   CONGRESS  47 

character  of  the  lesions  referred  to  by  Prof.  Campana,  in  connection 
with  which  there  seemed  to  have  been  some  misunderstanding. 

Dr.  Dyer  said  he  believed  it  was  the  experience  of  everyone  who 
lived  in  a  leper  centre  that  the  bacilli  of  leprosy  became  attenuated 
with  the  attenuation  of  the  types  of  the  disease.  In  other  words, 
that  the  trophic  types  were  evidence  of  the  fact  that  the  disease 
was  more  or  less  effete.  An  observation  of  a  number  of  cases  in 
the  lazaretto  in  Havana  seemed  to  show  that.  They  pointed  with 
a  large  degree  of  suggestive  argument  to  the  fact  that,  although 
that  institution  had  existed  for  many  decades,  there  was  not  a 
single  instance  of  infection  occurring  in  the  hospital  itself.  Dr. 
Thompson  of  New  South  Wales  had  argued  that  only  those  cases 
that  showed  the  deformities  of  leprosy  should  be  dismissed,  because 
they  were  no  longer  active.  Those  who  lived  in  leper  centres 
knew  from  experience  that  the  disease  spread  gradually,  and, 
while  it  could  not  be  traced  from  individual  to  individual,  it  spread 
numerically  wherever  it  had  been  introduced.  Personally,  he 
believed  in  fighting  the  disease  to  a  finish.  In  Louisiana  they  had 
had  since  1894  something  like  two  hundred  and  forty  cases  under 
observation  at  various  times,  and  on  an  average  there  had  always 
been  from  fifty  to  sixty  cases  at  the  leper  home.  The  method  of 
isolation  practiced  there  had  apparently  not  only  reduced  the  num- 
ber from  year  to  year,  but  had  reduced  it  to  nearly  one  quarter 
what  it  was  when  isolation  was  commenced.  Almost  every  one  of 
the  new  cases  showed  the  evidences  of  acute  leprosy,  meaning  by 
that  leprosy  of  an  acute  macular  type,  or  showing  distinct  tubercu- 
lar evidence  of  the  disease.  The  cases  which  were  purely  trophic  in 
type  were  evidently  ancient  cases,  but  the  newer  cases  have  been  of 
the  macular  type,  and  suggestive  of  a  recent  leprous  nerve  infection. 

Dr.  Dyer  said  he  had  received  some  notoriety  as  having  effected 
some  cures  in  leprosy.  The  good  results  they  had  obtained  in 
Louisiana  were  largely  due  to  the  fact  that  they  had  come  to  re- 
gard the  treatment  of  leprosy  as  practically  the  same  as  that  of 
tuberculosis.  The  patient  received  plenty  of  fresh  air  and  sun- 
shine, with  two  or  three  baths  daily,  as  warm  as  could  be  borne. 
In  addition  to  this,  they  had  followed  the  traditional  treatment 
of  leprosy,  depending  mainly  on  chaulmoogra  oil  and  strychnine, 
but,  in  cases  where  this  oil  could  not  be  tolerated  in  large  doses, 
cod  liver  oil  or  some  other  oil  was  substituted  with  practically 
equally  good  results.  Under  this  general  method  of  treatment, 
after  two  or  three  years,  some  good  results  were  achieved,  and  in 
some  sixteen  cases  evidences  of  the  disease  were  removed. 


48  SIXTH   INTERNATIONAL 

DR.  PRINCE  A.  MORROW,  of  New  York  City,  said  the  views  ex- 
pressed by  Prof.  Campana  were  certainly  somewhat  startling. 
Personally,  he  thought  it  was  impossible  to  say  whether  the  bacilli 
which  escaped  from  the  lesions  of  advanced  tubercular  leprosy 
were  dead  or  alive.  There  was  absolutely  no  culture  method  which 
could  be  relied  upon,  nor  was  there  any  experimental  method.  Dr. 
Morrow  said  he  would  not  be  willing  to  accept  Prof.  Campana's 
statement — in  spite  of  the  fact  that  it  seemed  very  positive  and 
absolute — without  a  more  thorough  knowledge  of  the  basis  of  his 
statements.  It  would  be  a  practical  impossibility  to  isolate  cases 
of  leprosy  only  during  the  early  stages  of  the  disease,  simply  because 
in  a  large  proportion  of  cases  the  disease  remained  undetected  in 
those  stages.  It  was  a  matter  of  general  knowledge  that  leprosy 
might  exist  for  five,  ten,  fifteen,  twenty,  and  even  thirty  years, 
with  positive  evidences  of  the  disease  on  the  skin  in  the  shape  of 
macules  and  certain  nerve  lesions,  and  still  remain  unrecognized 
by  the  physician  without  a  very  thorough  examination.  That 
was  the  reason  why  we  could  not  exclude  leprosy  from  this  country 
— because  we  did  not  recognize  it  in  its  early  stage.  Even  in  cases 
of  tubercular  leprosy  there  were  certain  prodromata  or  initial 
symptoms  which  might  entirely  escape  observation,  and  the  nature 
of  which  could  not  be  determined  with  absolute  certainty  without 
a  microscopic  examination.  He  thought  it  would  be  very  difficult 
for  Prof.  Campana  or  any  one  else  to  indicate  the  precise  period 
in  the  evolution  of  the  disease  when  these  bacilli  lost  their  virulence 
or  activity.  As  a  matter  of  fact,  he  thought  it  would  be  impossible, 
and  he  did  not  believe  that  we  would  be  justified  in  trying  to 
distinguish  between  these  two  classes  of  cases.  There  were  cases 
on  record  in  which  the  infection  was  traced  to  advanced  cases. 

So  far  as  the  anaesthetic  cases  were  concerned,  Dr.  Morrow  said 
he  had  always  been  incredulous  as  to  their  danger  from  a  contagious 
point  of  view.  He  thought  it  was  largely  due  to  a  paper  which  he 
read  before  the  New  York  Academy  of  Medicine  that  the  Board  of 
Health  of  this  city  adopted  a  different  method  of  policy  in  dealing 
with  these  cases.  At  any  rate,  after  that  paper  was  read,  a  number 
of  lepers  who  were  isolated  on  North  Brother  Island  were  quietly 
allowed  to  escape. 

In  the  anaesthetic  cases,  the  speaker  said,  the  bacilli  were  im- 
bedded in  the  nerves  or  deeper  tissues;  they  were,  to  a  certain 
extent,  encapsulated  or  isolated,  and  found  no  means  of  egress, 
and  for  that  reason  this  type  of  cases  could  not  be  regarded  as 
dangerous  sources  of  infection. 


DERMATOLOGICAL   CONGRESS  49 

Dr.  Morrow  said  there  was  another  point  to  which  he  wished 
to  refer,  and  that  was  the  need  of  revolutionizing  our  idea  that 
leprosy  was  an  incurable  disease.  He  had  had  at  least  two  cases 
in  this  city  in  which  the  disease  had  been  absolutely  cured  without 
a  vestige  remaining,  and  in  one  of  those  cases  the  cure  had  per- 
sisted for  over  ten  years.  These  particular  patients  were  treated 
with  chaulmoogra  oil,  strychnine,  and  electricity.  Of  course,  it 
was  difficult  to  say  how  much  the  actual  treatment  had  to  do  with 
the  cure  in  these  cases,  because  it  was  a  well-recognized  fact  that 
lepers  who  removed  to  a  favorable  climate  usually  showed  more 
or  less  improvement.  In  the  leper  colony  at  Molokai,  after  various 
methods  of  treatment  had  been  tried,  the  best  results  were  claimed 
from  small  doses  of  chaulmoogra  oil  and  strychnine.  Dr.  Morrow 
said  he  had  obtained  this  information  from  a  personal  letter  re- 
cently received  from  a  gentleman  who  had  charge  of  the  male 
leper  colony  at  Kalawao. 

There  was  another  point  to  which  he  wished  to  refer,  and  that 
was  the  spontaneous  limitation  of  the  disease.  Certain  obser- 
vations had  also  been  made  at  Kalawao  in  order  to  substantiate 
Dr.  Morrow's  view  that  the  infection  of  leprosy  occurred  in  the 
nasal  and  upper  laryngeal  passages.  He  had  recently  received 
a  report  of  ten  cases  in  which  the  disease  existed  for  periods  ranging 
from  eight  to  fifteen  years,  showing  absolutely  no  tendency  to 
get  worse.  In  some  of  the  cases  the  conditions  apparently  re- 
mained stationary,  while  in  the  majority  an  improvement  had 
been  noticed.  In  three  of  the  cases  all  evidence  of  the  disease 
had  disappeared,  and  the  speaker  said  he  agreed  with  Dr.  Brincker- 
hoff  that  the  knowledge  should  be  more  generally  disseminated 
that  leper  patients  who  went  to  Molokai  did  not  necessarily  go 
there  to  die.  If  people  who  were  afflicted  with  leprosy  knew 
that,  there  would  be  less  opposition  to  this  measure  of  segregation, 
and  patients  would  come  under  observation  earlier  in  the  course 
of  the  disease. 

DR.  WILLIAM  T.  CORLETT,  of  Cleveland,  said  that  last  winter 
he  had  had  the  opportunity,  with  two  colleagues,  of  visiting  the 
leper  hospital  at  Port-of-Spain  in  Trinidad.  This  hospital  con- 
tained two  hundred  and  sixty  inmates,  most  of  them  well  advanced 
in  the  disease,  and  he  was  informed  by  the  Sister  who  had  charge 
of  the  hospital  that  not  a  single  instance  of  infection  had  occurred 
among  any  of  the  hospital  attendants  during  the  entire  course  of 
her  sojourn  there,  which  was  about  thirty-five  years.  In  that  en- 

VOL.  I. — 4 


So  SIXTH   INTERNATIONAL 

tire  period  she  had  been  absent  from  the  hospital  less  than  five 
years.  She  pointed  out  other  Sisters  who  had  been  there  almost 
as  long  as  she,  and  in  no  instance  had  infection  taken  place. 

Dr.  Corlett  said  he  believed  it  was  rare  that  infection  occurred 
among  attendants  in  a  leper  hospital,  and  he  thought  this  brought 
out  a  clinical  point  in  favor  of  what  Prof.  Campana  had  said. 

DR.  PRINCE  A.  MORROW,  of  New  York,  said  that  in  order  to 
offset  the  effect  of  Dr.  Corlett 's  statement  he  might  mention  the 
fact  that  the  gentleman  who  had  charge  of  the  male  leper  colony 
at  Kalawao  went  there  directly  from  the  United  States  and  three 
years  after  his  arrival  there  he  fell  a  victim  to  the  disease.  Dr. 
Morrow  examined  him  at  that  time,  and  found  unmistakable 
evidences  of  leprosy.  Since  then  characteristic  signs  of  the  disease 
had  developed,  including  deformities  of  the  toes,  which  were  the 
only  remaining  evidences  of  the  disease  at  present.  For  a  number 
of  years  he  had  lost  the  power  of  one  leg. 

Dr.  Morrow  said  he  knew  of  at  least  three  physicians  who  con- 
tracted leprosy  in  the  Sandwich  Islands.  On  the  other  hand,  ex- 
amples to  the  contrary  were  not  wanting.  He  recalled  the  case 
of  a  man  who  lived  with  his  leper  daughter  for  over  thirty  years 
without  contracting  the  disease,  although  his  wife  and  a  second 
daughter  subsequently  contracted  it.  All  of  these  cases  were 
well-marked  examples  of  tubercular  leprosy.  He  also  recalled 
the  case  of  a  washerwoman  who  had  washed  the  clothes  of  lepers 
for  seventeen  years  and  had  been  exempt  during  this  period,  but 
who  fell  a  victim  to  the  disease. 

Dr.  Morrow  said  he  did  not  think  the  exemption  of  hospital 
attendants  or  Sisters  of  Charity  was  strong  evidence  of  the  fact 
that  a  disease  was  not  contagious.  One  might  as  well  say  that 
syphilis  was  not  contagious  because  it  is  scarcely  ever  contracted 
by  hospital  attendants  or  helpers. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  wished  to  add 
a  few  words  in  confirmation  of  what  Dr.  Morrow  had  said  in  re- 
gard to  prognosis.  There  were  two  classes  of  cases:  one,  the  mild 
form  in  which  the  symptoms  might  continue  for  an  interminable 
number  of  years,  and  some  of  these  patients  got  quite  well.  He 
recalled  the  case  of  a  woman,  about  forty,  who  contracted  leprosy 
in  a  very  mild  form;  she  was  under  his  observation  for  eight  or 
nine  years.  The  last  time  he  saw  her  she  was  entirely  free  from 
the  characteristic  rings,  which  were  the  only  symptom  she  had 
ever  exhibited  of  the  eruption.  He  also  recalled  two  cases  of  the 


DERMATOLOGICAL   CONGRESS  51 

tubercular  type,  which  were  both  treated  by  chaulmoogra  oil. 
One  of  the  patients  was  a  native  of  Peru  who  was  able  to  take  500 
minims  of  the  oil  a  day  and  was  completely  cured.  He  recalled 
another  case,  a  woman  who  had  spent  many  years  in  India  as  a 
matron  in  a  leper  asylum;  she  was  brought  to  him  to  confirm  the 
fact  that  she  was  absolutely  free  from  all  symptoms  of  the  disease, 
as  she  wished  to  go  to  the  United  States  and  did  not  care  to  run 
the  risk  of  segregation  in  a  leper  colony. 

Dr.  Crocker  asked  Dr.  Dyer  whether  he  had  tried  the  mercurial 
injection  treatment,  of  which  the  speaker  had  been  an  advocate. 
While  the  treatment  did  not  effect  a  cure,  it  produced  a  great 
reduction  in  the  amount  of  infiltration,  as  well  as  a  general  im- 
provement in  the  patient  for  long  periods  of  time.  In  corrob- 
oration  of  this  statement,  he  hoped  to  exhibit  photographs  showing 
the  condition  of  patients  before  and  after  this  method  of  treatment 
and  in  these  cases  the  improvement  was  very  rapid  and  obvious. 

Leprosy,  Dr.  Crocker  said,  was  by  no  means  a  hopeless  disease, 
and  in  the  mild  nerve  forms  the  prognosis  was  fairly  good.  At  all 
events,  the  duration  of  the  disease  was  so  long  and  the  symptoms 
so  trifling  that  they  scarcely  incommoded  the  patient. 

DR.  BURNSIDE  FOSTER,  of  St.  Paul,  said  that  his  experience 
with  leprosy  among  the  Scandinavians  in  the  North,  mostly  Nor- 
wegians, had  led  him  to  recognize  the  communicability  of  the 
disease,  but  he  believed  that  it  was  communicated  with  great 
difficulty,  and  that  it  could  only  be  engrafted  upon  a  peculiar 
soil.  Furthermore,  that  there  were  many  who  could  not  be 
inoculated  with  it. 

Dr.  Foster  said  he  was  glad  Dr.  Morrow  had  mentioned  the 
possibility  of  the  spontaneous  disappearance  of  the  disease.  The 
Scandinavians  knew  more  about  leprosy  than  most  doctors  do; 
they  were  able  to  recognize  it  from  its  inception,  and  carefully 
concealed  the  evidences  of  it  as  long  as  possible.  Many  of  the 
cases  existed  for  many  years  without  being  detected  by  the  author- 
ities, and  he  knew  of  several  instances  where  the  symptoms  dis- 
appeared after  the  disease  had  been  in  existence  for  fifteen  years 
and  longer.  In  one  case  where  the  bacilli  had  been  repeatedly 
found  they  finally  disappeared.  It  was  a  case  of  tubercular  leprosy 
in  which  the  disease  disappeared  spontaneously,  leaving  deformities. 

PROF.  CAMPANA,  in  closing  the  discussion,  said  that,  while  he 
was  sorry  that  any  exception  had  been  taken  to  the  views  ex- 
pressed in  his  paper,  he  did  not  wish  to  have  it  understood  that 


52  SIXTH  INTERNATIONAL 

he  was  opposed  to  isolating  cases  of  leprosy,  because  it  was  very 
difficult  to  state  the  exact  time  when  the  infective  period  of  the 
disease  disappeared.  He  simply  wished  to  insist  on  the  scientific 
accuracy  of  the  observation  that  the  infectious  character  of  the 
disease  disappeared  with  the  full  development  of  the  disease,  and 
that  in  order  to  prevent  the  spread  of  the  disease  it  was  neces- 
sary to  destroy  the  sources  of  infection  in  the  patient.  Nothing 
was  said  against  the  advisability  of  protecting  the  community 
from  the  spread  of  leprosy  by  proper  segregation. 


ON  THE  PRESENT  POSITION  OF  THE  LEPROSY 

QUESTION 

BY  JONATHAN  HUTCHINSON,  F.R.S.,  L.LD.,  London 

Since  the  publication  of  my  work  on  Fish  Eating  and 
Leprosy  now  nearly  two  years  ago,  I  have  received  many 
communications  on  the  subject  from  various  parts  of  the 
world.  Almost  without  exception,  these  have  been  to  the 
effect  that  the  hypothesis  advocated  was  eminently  applicable 
to  the  district  with  which  the  writer  was  acquainted.  I 
will  now  deal,  therefore,  only  with  those  which  contested  my 
conclusions. 

BASUTO-LAND 

Observers  in  Basuto-land  have  urged  that  in  that  country 
very  little  fish  is  eaten,  while  leprosy  is  yet  prevalent.  This 
allegation  is  one  with  which  I  have  long  been  acquainted,  and 
it  was  one  of  the  chief  objects  of  my  visit  to  South  Africa 
in  1901  to  investigate  it  on  the  spot.  Owing,  however,  to  the 
war,  then  not  concluded,  I  was  unable  to  get  into  that  terri- 
tory. Basuto-land  is  a  mountainous  inland  district  and  is 
sometimes  called  the  Switzerland  of  South  Africa.  It 
is  inhabited  by  a  hardy  race  of  Bantu  descent.  No  fish 
is  obtained  there,  and  what  is  eaten  is  all  or  nearly  all 
imported.  There  is  no  prejudice  against  salt-fish;  on  the 
contrary,  the  Basutos  are  exceedingly  fond  of  it  and  only 
their  poverty  prevents  its  liberal  use.  Tinned  fish  in  the  form 
of  sardines  is  very  eagerly  purchased  and  in  considerable 
quantities ;  but  it  is  said  that  the  cheaper,  and  in  my  opinion 


DERMATOLOGICAL  CONGRESS  53 

really  dangerous,  kind  known  in  Cape  Colony  and  the  Trans- 
vaal as  "Sack-fish"  does  not  find  its  way  into  "the  Switzerland 
of  South  Africa."  The  Basutos  are,  however,  like  the  rest  of 
the  Kaffir  tribes,  travellers,  and  great  numbers  of  the  younger 
men  go  for  a  time  to  the  mining  centres  in  search  of  work. 
At  Queenstown  I  was  fortunate  enough  to  meet  with  one  of 
these  Basuto  immigrants  who  was  a  leper.  He  had  lived  long 
in  Cape  Town,  and  he  told  me  that  he  had  eaten  much  salt- 
fish  and  that  all  his  countrymen  did  so  whenever  they  could 
get  it.  If  then  we  allow  ourselves  to  suspect  that  those  who 
have  reported  no  fish-eating  and  much  leprosy  in  Basuto- 
land  may  have  unintentionally  somewhat  exaggerated  the  pre- 
valence of  the  disease  and  minimized  the  consumption  of 
cured  fish  whilst  neglecting  to  ascertain  the  influence  of  tem- 
porary migration,  there  does  not  seem  to  be  any  great  bulk 
of  facts  needing  to  be  explained.  I  am  glad  to  be  able  to 
believe  with  confidence  that  there  is  no  other  place  where  a 
case  so  seemingly  strong  can  be  stated,  and  I  regret  exceed- 
ingly that  it  has  not  been  possible  for  me  to  examine  the 
facts  personally  on  the  spot. 

OUTBREAK  IN  SWITZERLAND 

In  the  autumn  of  1896  sensational  statements  appeared  in 
the  European  press  as  to  an  outbreak  of  leprosy  in  European 
Switzerland.  In  the  middle  ages  there  were  many  leper- 
houses  scattered  over  the  Swiss  cantons,  and  one  of  the  latest 
to  survive  was  that  at  Sion  in  the  Rhone  Valley.  This  had, 
however,  been  closed  for  two  or  three  centuries  prior  to  the 
recent  outbreak,  and  during  this  period  there  had  been  no 
suspicion  as  to  the  existence  of  the  disease  in  Swiss  territory. 
It  is  needless  to  state  that,  while  more  than  half  of  the  Swiss 
population  had  early  embraced  Protestantism  and  renounced 
the  Catholic  fasts,  several  of  the  smaller  and  more  thinly 
populated  cantons  had  remained  true  to  the  older  form  of 
faith.  Amongst  the  latter  the  town  of  Sion  and  the  whole 
district  of  the  valley  of  the  Rhone  are  included. 

Being  very  sure  that  a  sudden  outbreak  of  leprosy  in  the 
Swiss  mountains  would  certainly  be  brought  forward  as  an 
argument  against  the  fish  hypothesis,  I  determined  to  visit  the 


54  SIXTH   INTERNATIONAL 

locality  and  investigate  the  facts.  Armed  with  proper  cre- 
dentials I  made  my  way  to  Sion,  and  en  route,  at  Lausanne 
and  Geneva,  obtained  from  professional  confreres  and  others 
as  much  information  as  I  could.  Every  one  assured  me  that 
I  should  find  no  consumption  of  fish,  either  fresh  or  cured,  in 
the  district  concerned.  All  fish  that  could  be  got  from  the 
mountain  streams  was  much  too  valuable  to  be  eaten  by  the 
peasants,  and  the  latter  were  too  poor  to  import  the  salted 
article.  Even  in  Sion  itself,  from  resident  officials,  to 
whom  it  was  necessary  for  me  to  apply  in  order  to  obtain 
access  to  the  patients,  the  same  statements  were  made  to  me 
in  the  most  confident  terms.  From  Sion  I  went  forward  to 
Leuche  (a  thirty-mile  journey)  with  a  puzzled  suspicion  that 
now  at  length  I  was  about  to  encounter  facts  which  it  would  be 
very  difficult  to  explain  away.  It  was  in  or  near  Leuche  that 
the  lepers  had  been  discovered.  On  arriving  there  I  called 
upon  the  medical  adviser  of  the  district  to  whom  I  had  govern- 
ment introductions.  He  gave  me  most  courteous  assistance 
and  at  once  arranged  to  climb  with  me  next  morning  to  the 
upland  village  of  Sittet  where  two  of  the  patients  lived.  On 
my  stating  that  I  supposed  that  the  peasants  got  no  salt 
fish  he  at  once  replied:  "Oh,  but  indeed  they  do!  They  keep 
their  fasts  on  salt  fish,  and  during  Lent  potatoes  and  salt 
fish  are  their  chief  food."  The  landlord  of  my  hotel  con- 
firmed this,  and  added  that  "stock  fish,"  with  which  he  was 
well  acquainted,  was  regularly,  during  the  season,  on  sale  at 
three  or  four  shops  in  the  little  village.  Yet  further  con- 
firmation was  obtained  from  the  peasants  themselves,  who 
said  that  they  always  ate  salt  fish  during  Lent  and  on  other 
fast  days,  excepting  during  summer,  when  it  could  not  be 
kept  good.  Subsequently  at  Berne,  through  the  kind  assistance 
of  Dr.  Gamgee,  I  obtained  statistics  of  the  importation  of 
salted  fish  for  the  Rhone  Valley  and  found  that  it  was  very 
considerable. 

We  may  then  consider  it  as  established  that  the  peasants 
in  the  village  where  the  leprosy  cases  have  occurred  do  con- 
sume salt  fish  rather  freely  and  that  their  fish  is  apt  to  go  bad 
in  warm  weather. 

The  introduction  of  fish  into  the  district  is  solely  in  order 


DERMATOLOGICAL   CONGRESS  55 

to  meet  the  requirements  of  a  Catholic  community  and  would 
not  take  place  were  it  not  for  the  fast  days. 

Thus  then  it  is  clear  that  the  recent  development  of  leprosy 
in  Switzerland,  so  far  from  confuting  the  fish  hypothesis,  gives 
it  valuable  support.  I  may  add  that  it  does  also,  in  the 
strongest  manner,  confute  the  suggestion  of  contagion.  There 
are  at  present  only  four  cases,  but  it  is  not  improbable  that  a 
few  have  occurred  in  the  same  village  during  the  last  fifty  years 
or  more,  whilst,  although  not  the  slightest  precautions  have 
been  taken,  there  has  been  no  spreading.  Two  of  the  four 
cases  (young  persons)  are  still  living  with  their  relatives  and 
the  others  have  been  only  very  recently  and  very  partially 
isolated.  Some  very  interesting  questions  respecting  Swiss 
leprosy  remain  for  discussion.  Why  did  the  disease  cease  in 
Switzerland  about  the  time  of  the  Reformation  although  some 
cantons  remained  Catholic?  We  do  not  know  enough  as  to 
the  social  history  of  the  time  to  be  able  to  answer  with 
confidence.  It  may  have  been  that  the  greatly  diminished 
demand  throughout  the  country  for  fast-day  fish,  made  it  im- 
possible for  the  poorer  classes  and  those  most  remote  from  the 
sources  of  supply,  among  whom  the  Catholics  would  be  num- 
bered, to  obtain  salt-fish  at  all.  Even  at  the  present  day  well- 
informed  residents  are  under  the  impression  that  the  peasants 
cannot  afford  it.  This  I  have  shown  to  be  a  mistake,  but  it 
remains  highly  probable  that  it  has  been  the  development  of 
traffic  (roads  and  railroads)  and  the  increase  of  wealth  which 
have  made  it  recently  accessible  and  thus  given  leprosy  a  fresh 
start. 

There  is  reason  to  believe  that  (as  in  almost  all  civilized 
countries)  there  have  been  during  the  last  century  numerous 
instances  of  exotic  lepers  coming  to  reside  in  Switzerland. 
In  many  such  cases  the  malady  has  not  been  recognized  and 
the  patient  has  continued  until  the  time  of  death  to  reside 
with  relatives.  Yet  no  outbreaks  have  occurred.  Two  such 
cases  I  myself  visited  with  their  medical  attendants  who  were 
well  aware  of  the  nature  of  the  disease,  yet,  although  both 
the  latter  were  avowed  contagionists,  in  neither  instance  was 
the  slightest  precaution  being  observed.  One  of  these  cases 
was  a  severe  one,  the  patient  being  quite  blind,  yet,  at  the 


56  SIXTH   INTERNATIONAL 

time  of  my  visit  to  him,  he  sat  in  his  garden  with  a  group  of 
children  about  him.  The  other,  a  milder  one,  was  an  inmate 
of  a  general  ward  at  a  hospital.  I  told  my  friends,  the  surgeons 
concerned,  that  while  I  applauded  their  personal  courage 
(for  they  visited  their  patients  regularly  and  touched  them 
freely) ,  I  could  not  approve  their  imprudence  in  thus  exposing 
themselves  and  others  to  a  risk  which  they  held  to  be  so 
terrible. 

LEPROSY   IN   FINMARKEN 

I  have  reserved  to  the  last  an  objection  to  the  fish-hy- 
pothesis which  has  recently  been  put  forward  by  the  greatest 
living  authority  on  leprosy,  my  much  honored  friend  Dr. 
Hansen.  With  that  candor  which  distinguishes  his  character, 
Dr.  Hansen  has  recently  fully  admitted  that  the  suggestion  of 
contagion  cannot  be  made  to  explain  the  facts  as  obtained 
in  Norway.  He  refuses,  however,  to  accept  any  food  explana- 
tion, and  he  has  in  a  recent  communication  to  Lepra  brought 
forward  facts  which  he  holds  confute  it,  more  especially  that  one 
which  traces  the  disease  to  decomposing  fish.  The  inhabitants 
of  Finmarken  are,  he  tells  us,  great  fish-eaters,  yet  they  suffer 
far  less  from  leprosy  than  do  their  fellow-countrymen  and  near 
neighbors  on  the  west  coast  of  Norway.  My  reply  to  this  is, 
that  Finmarken,  which  is  within  the  Arctic  circle  and  includes 
the  North  Cape  itself,  is  a  very  cold  region.  The  fish  are  frozen 
during  two-thirds  of  the  year.  The  west  coast,  although  so 
near,  has  a  wholly  different  climate.  It  is  under  the  influence 
of  the  Gulf  Stream  and  its  waters  are  always  comparatively 
warm.  The  fish  which  are  caught  decompose  if  kept  and  do 
not  freeze.  The  conditions  of  Finmarken  are,  I  believe,  very 
similar  to  those  of  Newfoundland,  and  in  both  places  leprosy 
although  present,  and  if  contagious  likely  to  spread,  does  not 
do  so.  The  explanation  is  the  same  in  both  and,  so  far  from 
confuting  the  fish-hypothesis,  strongly  supports  it. 

INCREASE  OF  LEPROSY  IN  SOUTH  AFRICA 

The  belief  in  contagion  has  received  a  damaging  blow 
from  recent  experience  in  South  Africa.  In  Cape  Colony  rigid 
enactments  for  the  segregation  of  all  lepers  have  been  carried 


DERMATOLOGICAL   CONGRESS  57 

out  for  many  years  with  cruel  and  vigorous  consistency, 
while  the  fish  traffic  has  been  left  uncontrolled.  The  result 
has  been  a  steady  and  very  considerable  increase  of  the  dis- 
ease, while  the  new  cases  have  occurred  not  near  to  any  leprosy 
centres,  but  scattered  over  the  agricultural  districts  among 
those  who  so  far  as  they  knew  had  never  been  exposed 
to  risk. 

SUMMARY 

Thus  I  think  that  the  believers  in  the  fish  origin  of  the 
disease  may  fairly  claim  that  the  evidence,  which  has  accrued 
since  my  book  was  published,  has  all  tended  to  strengthen  the 
conclusions  therein  advanced  and  to  discredit  those  of  the 
contagionists.  Although  the  fish-hypothesis  has  as  yet  but 
few  avowed  disciples,  yet  it  has,  I  believe,  exercised  a  wide- 
spread and  very  beneficial  influence.  Attention  has  been 
given  to  the  details  of  fish-curing,  the  importance  of  the  supply 
of  good  and  cheap  salt,  and  the  dangers  attending  the  con- 
sumption of  badly  cured  fish.  It  was  with  the  hope  of 
securing  these  objects,  without  needless  delay,  that  I  took  the 
somewhat  exceptional  step  of  bringing  the  facts  before  the 
public  as  well  as  before  my  own  profession.  I  cannot  regret 
that  I  did  so.  The  question  still  remains  one  of  circumstantial 
evidence,  and  the  facts  require  for  their  correct  appreciation 
more  time  and  attention  than  most  of  our  profession  are  able 
to  give  to  them.  It  was  absolutely  necessary  if  possible  to 
convince  the  public. 

RECOVERIES 

I  may  just  add  that  I  have  had  recently  some  good  exam- 
ples of  recovery  from  leprosy  under  treatment.  My  personal 
conviction  is  that  leprosy  will  eventually  take  its  place  as  a 
form  of  tuberculosis  in  which  a  somewhat  specialized  bacillus 
finds  its  entrance  almost  solely  by  the  mouth.  It  will  be 
recognized  that  it  is  self -curable,  if  the  supply  of  the  parasite 
be  stopped,  under  similar  measures  to  those  which  are  found 
useful  in  other  tuberculous  affections. 


TRAITEMENT  DU  LEPROME  PAR  LA  PERFORA- 
TION ET  LA  CAUTERISATION  IGNEE 

PAR  LE  DR.  JOSE  VINETA-BELLASERRA,  BARCELONA 
Extrait  : 

Les  16preux  ont  fre"quemment  des  acces  febriles  plus  ou 
moins  intenses  et  de  plus  ou  moins  longue  dur6e.  Ces  acces 
ont  d£ja  6te"  signals  par  les  me"decins  du  moyen  age. 

Sou  vent  la  fievre  est  tellement  16gere  que  le  malade  n'y 
prete  pas  attention.  Ce  sont  de  petits  acces  de  fievre  passagers 
fugitifs,  intermittents.  Plusieurs  malades  les  prennent  pour 
des  acces  de  fievre  palude'enne.  D'autres  aussi  attribuent 
leur  fievre  a  un  refroidissement.  Ces  acces  apparaissent  ge'ne'- 
ralement  le  soir  ou  1'apres-midi. 

Dans  d'autres  cas  de  grands  frissons  agitent  le  corps  et 
Ton  constate  une  forte  61eVation  de  la  temperature.  Ces 
frissons,  cette  fievre,  sont  parfois  tellement  intenses,  qu'ils 
rappellent  le  frisson  de  la  pneumonie  aigue,  de  la  variole,  etc., 
et  que  le  sujet  se  croit  atteint  d'une  fluxion  de  poitrine,  due 
a  un  refroidissement,  ou  d'une  affection  quelconque  k  d6but 
febrile  intense. 

Je  ne  d6crirai  pas  ici  les  lepromes,  que  vous  connaissez 
tres  bien ;  je  dirai  seulement  qu'il  se  pre"sente  souvent  une  fievre 
subite  et  intense,  accompagne'e  de  troubles  digestifs  infectieux 
qui  compromettent  la  vie  du  malade,  coincident  aussi  avec 
1'infiltration  et  la  suppuration  des  tubercules  l£preux.  Quel- 
quefois  ils  coincident  avec  1'invasion  de  1'^ruption  bulleuse 
(pemphigus  leprosus)  des  pouss^e  lymphangitiques  et  des 
osdemes  masquant  le  volume  ordinaire  de  la  region  attaqu£e. 

Quand  je  constate  tous  ces  symptomes,  je  prends  la  pointe 
fine  du  termo-  ou  galvano-cautere,  et  je  precede  de  suite  a  la 
perforation  et  la  cauterisation  igne6  de  tous  les  tissus  envahis 
par  le  germe  16preux.  Aussit6t  cette  operation  ex6cutee,  on 

58 


SIXTH   INTERNAT.  DERMATOL.  CONGRESS          59 

voit  sortir  une  quantite  assez  considerable  de  pus.  Une  fois 
de"gage"e  de  cette  pourriture  des  regions  atteintes,  la  lymphangite 
disparait  de  suite,  ainsi  que  les  symptdmes  ge"ne"raux:  fievre, 
troubles  intestinaux,  nerveux,  etc. 

Concernant  l'e"tat  ge"ne"ral  des  malades,  je  soumets  d'abord 
ceux-ci  a  une  bonne  nourriture,  a  la  medication  tonique,  sur- 
tout  au  sulfate  de  quinine,  a  1'huile  de  Chaulmoogra  a  hautes 
doses,  et  pour  la  disinfection  du  tube  digestif,  au  benzonaphtol. 

Ayant  obtenu  de  tres  bons  r£sultats,  j'ai  essaye"  le  meme 
proc6d6  pour  atrophier  les  masses  tuberculeuses,  surtout  dans 
toutes  les  regions  du  visage,  et  j'ai  e"galement  obtenu  de 
brillants  succes. 


LE  TRAITEMENT  DU  LUPUS  VULGAIRE  PAR  LA 
TUBERCULINS  DE  BER^NECK 

PAR  LE  DR.  A.  LASSUEUR,  LAUSANNE 

La  decouverte  de  la  radiothe"rapie  et  de  la  phototherapie, 
m6thodes  qui  sont  venues  enrichir,  presque  simultane'ment,  la 
the"rapeutique  du  lupus  vulgaire,  a  fait  oublier  les  essais  tenths 
avec  la  tuberculine,  essais  qui  avaient  &£  cependant  couronne's 
de  quelques  succes  incontestables. 

Aujourd'hui,  1'enthousiasme  qu'avait  suscit6  les  premiers 
r6sultats  obtenus  par  les  rayons  X  et  les  rayons  ultra- violets,  a 
certainement  diminue'.  Une  experimentation  suffisamment 
longue,  est  venue  de"montrer  qu'il  y  a  des  cas  de  lupus,  qui  ne 
sont  que  peu  ou  pas  influence's  par  les  rayons  X,  et  qu'il  en 
est  d'autres,  qui,  de  par  leur  £tendue  et  leur  siege  surtout, 
sont  non  pas  impossibles,  mais  bien  difficiles  a  traiter  par  la 
me"thode  Finsen. 

Les  anciennes  me"thodes  de  traitement  du  lupus  qui  cepend- 
ant avaient  fait  leur  preuve,  mais  que  le  dermatologue  s'e"tait 
trop  empresse"  d'abandonner,  reprennent  aujourd'hui — lente- 
ment  il  est  vrai — la  place  qui  leur  est  due  dans  la  theYapeutique 
du  lupus  tuberculeux.  La  diversite"  des  cas  de  lupus  est  telle, 
du  reste,  que  1'on  ne  peut  songer  a  voir  un  seul  et  unique  traite- 
ment employe",  dans  tous  les  cas  avec  le  m6me  succes.  Les 


60  SIXTH   INTERNATIONAL 

agents  physiques,  employes  en  theVapeutique,  ne  varient-ils 
pas  dans  leurs  effets,  suivant  les  individus,  tout  autant  que 
les  agents  chimiques? 

La  radioth£rapie  et  la  photothe'rapie  dont  les  indications 
vont  en  se  pre"cisant  tou jours  davantage,  ne  doivent  pas  faire 
oublier,  nous  le  re'pe'tons,  les  anciennes  m£thodes  qui  ont  le 
grand  avantage  d'etre  plus  simples  et  a  la  porte'e  de  chacun. 
Elles  laissent,  en  tout  cas,  dans  la  the'rapeutique  du  lupus 
vulgaire  une  place  pour  de  nouvelles  recherches : 

Ceci  dit  pour  justifier  les  essais  que  nous  nous  sommes  permis 
de  tenter  dans  notre  clientele  prive'e,  sur  quelques  malades 
atteintes  de  lupus,  avec  une  nouvelle  tuberculine,  celle  du 
P-  Beraneck,  de  Neuchatel. 

C'est  la  lecture  du  remarquable  travail  de  M'Call  Anderson, 
sur  lequel  nous  reviendrons  tout  a  1'heure,  et  les  re"sultats 
encourageants  obtenus  par  le  traitement  a  la  tuberculine  dans 
les  tuberculoses  chirurgicales  qui  nous  ont  encourag6  k  reprendre 
ce  traitement  dans  le  lupus  vulgaire.  Nous  avons  choisi  la 
tuberculine  de  Beraneck,  de  pr6f6rence  aux  autres,  parce  que 
son  emploi  est  facile,  exempt  de  danger,  et  que  the'oriquement 
elle  nous  paraissait  superieure  aux  autres.  Preparee  dans 
notre  pays,  nous  pouvions  1'obtenir  aussi  plus  facilement 
qu'aucune  autre. 

De  toutes  les  tuberculines  connues  jusqu'k  ce  jour,  aucune 
n'a  encore  tenu  toutes  les  belles  promesses  de  ses  parrains  et 
realise  toutes  les  espe'rances  qu'on  attendait  d'elle  dans  le 
traitement  de  la  tuberculose  pulmonaire.  Cela  est  vrai.  Mais 
dans  des  tuberculoses  plus  benignes,  plus  circonscrites  (chirurgi- 
cales par  exemple)  eVoluant  sur  un  sujet  en  sant6  apparente 
parfaite,  exempt  tout  au  moins  de  lesions  pulmonaires,  le 
traitement  a  la  tuberculine  a  donn6  des  r£sultats  encourageants. 
Cela  est  incontestable.  Au  patient  labeur  du  savant  de  labora- 
toire,  qui  cherche  dans  les  divers  modes  de  preparation  de  la 
tuberculine,  celui  qui,  the'oriquement,  lui  parait  le  plus  exact, 
doit  done  s'unir  I'expenmentation  du  clinicien  et  ses  observa- 
tions sur  le  malade.  Trop  de  m6decins  decourages  par  la 
faillite  d' autres  se'rums  ou  ayant  encore  present  a  1' esprit  les 
d£sastres  qui  suivirent  les  premiers  essais  pratiques  avec  la 
tuberculine  de  Koch,  se  refusent  a  employer  les  nouvelles 


DERMATOLOGICAL  CONGRESS  61 

tuberculines.  Us  cachent  volontiers  leur  parti-pris  sous  des 
apparences  humanitaires,  en  re"p£tant  bien  haut  que  les  malades 
ne  sont  pas  des  cobayes! 

D'autres  me"decins,  attendent  que  les  chimistes  aient  extrait 
et  dose"  les  substances  actives  de  la  tuberculine,  ne  voulant 
pas  employer  un  remede  dont  ils  ignorent  la  composition 
exacte. 

Cette  facon  de  raisonner  ne  nous  parait  pas  tres  juste,  et 
nous  dissipons  a  1'avance  les  craintes  de  ces  confreres  timore's, 
en  leur  disant  que  des  1'instant  ou  le  traitement  a  la  tuberculine 
cesse  d'etre  dangereux,  nos  malades  cessent  d'etre  des  cobayes, 
et  que  si  nous  voulions  attendre  de  connaitre  la  nature  ou  la 
composition  exacte  de  tous  les  agents  the'rapeutiques  pour  les 
employer,  nos  malades  perdraient  le  be'ne'fice  de  methodes 
the'rapeutiques  pourtant  singulierement  efficaces.  Le  traite- 
ment de  la  leuce"mie  par  les  rayons  X  en  est  un  exemple  entre 
mille. 

Le  me"decin  ignore  la  cause  premiere  de  la  leuce"mie  et  la 
nature  des  rayons  X.  Cela  ne  1'empe'che  pas  de  traiter  la 
leuce"mie  par  les  rayons  X,  car  il  lui  suffit  de  comparer  ce  qui 
se  passe  avant  et  apres  le  traitement,  pour  croire  a  1'efficacite' 
de  la  me"thode,  quand  bien  me'me  il  ignore  totalement  ce  qui 
se  passe  pendant  le  traitement ! 

Aucun  travail  n'a  encore  paru  sur  le  traitement  du  lupus 
vulgaris  par  la  tuberculine  de  Be'raneck.  En  feuilletant  la 
litte"rature  dermatologique  de  ces  cinq  dernieres  anne"es,  nous 
avons  trouv6  la  relation  de  quelques  cas  de  lupus  trace's  par  la 
tuberculine  de  Koch,  qu'il  nous  parait  inte'ressant  de  returner. 

En  1905,  M'Call  Anderson1  a  publi6  une  seYie  de  cas 
de  lupus  gue"ris  par  les  injections  de  tuberculine.  Les  photo- 
graphies qui  accompagnent  ce  travail  sont  des  plus  con  vain  - 
cantes  et  ne  laissent  subsister  aucun  doute  sur  I'efricacit6 
de  ce  traitement,  attendu  que  le  lupus  ne  gue"rit  pas  spontane"- 
ment,  que  les  malades  n'ont  etc"  soumis  a  aucune  autre  me"dica- 
tion  et  qu'il  ne  saurait  s'agir  d'erreur  de  diagnostic. 

>  "A  Plea  for  the  More  General  Use  of  Tuberculin  by  the  Profession,"  by 
T.  M'Call  Anderson,  M.D.  The  British  Journal  of  Dermatology,  1905. 

II  y  a  cependant  eu  un  travail  ant6rieur  public"  par  B.  Cranston  Low 
paru  dans  le  n°  1905  du  Scottish  Medical  and  Surgical  Journal. 


62  SIXTH   INTERNATIONAL 

Darier  1  a  pre'sente'  en  1905,  a  la  Soci6t6  de  Dermatologie 
de  Paris,  un  jeune  homme  de  22  ans,  atteint  d'un  lupus  vulgaire 
de  la  face  et  du  cou,  y  compris  le  nez  et  les  oreilles,  gueVi  par 
des  injections  de  tuberculine.  Les  progres  de  la  guerison 
avaient  £t6  extre'mement  rapides. 

R.  Crocker  et  G.  Fernet 2  ont  obtenu  e'galement  des  r6sul- 
tats  tres  satisfaisants  avec  la  tuberculine  de  Koch  dans  les 
formes  ulce"reuses  et  chez  les  enfants  surtout.  Us  recomman- 
dent  le  traitement  a  la  tuberculine,  comme  adjuvant  des 
m£thodes  op6ratoires. 

Malcolm  Morris 3,  apres  une  exp6rimentation  personnelle 
relativement  longue,  conclut  a  1'utilite1  des  injections  de  tuber- 
culine, qui  si  elles  ne  gueYissent  pas  toujours,  rendent  souvent 
un  traitement  ult6rieur  plus  facile. 

Avant  de  re'sumer  nos  observations  personnelles,  nous 
de"crirons  en  quelques  mots  la  tuberculine  de  BeYaneck  et  la 
technique  que  nous  avons  adopted. 

La  tuberculine  de  Beraneck  qui  differe  essentiellement  de 
celle  de  Koch,  est  un  melange  de  toxines  extra-cellulaires, 
elabore"es  dans  un  bouillon  de  cultures  de  composition  spe"ciale 
et  de  toxines  extra-cellulaires  extraites  des  corps  bacillaires 
par  de  1'acide  orthophosphorique  a  i%.  Cette  tuberculine 
n'a  pas  que  des  proprie"t6s  immunisantes,  elle  exerce  aussi 
sur  le  bacille  de  Koch  soit  une  action  bacte'ricide  lorsqu'on 
1'emploie  en  solution  concentred ;  soit  une  simple  action  atten- 
uatrice  lorsqu'on  1'emploie  en  solution  dilute.4 

La  tuberculine  Beraneck  est  livre'e  dans  le  commerce  en 
15  solutions  principales  de'signe'es  par  les  symboles  ^;  ~;  ^-; 

w;  -T>  -T'  -T'  4-;  A;  B;  c;  D;  E;  F;G;  H-  La  solution 

1  Darier  "  Lupus  tuberculeux  de  la  face  datant  de  cinq  ans  gue"ri  en  trois 
mois  par  des  injections  de  tuberculine."     Annales  de  Dermat.,  1905,  p.  249. 

2  R.  Crocker  and  G.  Fernet.      "The   T.  R.    Tuberculine  Treatment   of 
Lupus  Vulgaris  at  University  College  Hospital."     British  Medical  Journal, 
1902. 

3  Malcolm  Morris.     "  Die  Behandlung  der  Lupus  vulgaris  wahrend  der 
letzten  funf-und-zwanzig  Jahre."      V.  Internation.  Dermatol.  Congress,  Ber- 
lin, 1904. 

*  Pour  le  mode  de  preparation  de  la  tuberculine  B6raneck,  consulter: 
Revue  Medicale  de  la  Suisse  Romande,  20  octobre,  1905.  "  Une  nouvelle 
tuberculine,"  par  Ed.  Be"raneck. 


DERMATOLOGICAL  CONGRESS  63 

la  plus  faible  est  ^;  la  plus  forte  est  H.  Chacune  de  ces  so- 
lutions, en  commangent  par  ^  est  deux  fois  plus  forte  que  la 

pre'ce'dente ;  -^  contient   done   deux  fois  plus  de  tuberculine 

'. 

que  £-•  -^  en  contient  deux  fois  plus  que  .-^-  et  ainsi  de  suite. 

•*•  l^o         o^  •••  i         _i   O4 

La  tuberculine  est  dilute  dans  de  la  solution  physiologique.  En 
supposant  que  H  repre"sente  la  tuberculine  BeYaneck  pure,  le 
Prof.  Dr.  Sahli  a  etabli  l'e"chelle  suivante: 

H  =  TBK.     (Tuberculine  Beraneck  pure) 

G  =  TKB/2  -^  =  TBK/256 

F  =  TBK/4  -f-  =  TBK/5I2 

E  =  TBK/8  -|-  =  TBK/I024 

D  =  TBK/i6  -^  =  TBK/2048 

C  =  TBK/32  ±  =  TBK/4o96 

B  =  TBK/64  £  =  TBK/8i92 

A  =  TBK/I28  jfg  =  TBK/i6384,  etc. 

Chaque  flagon  contient  10  cc.  d'une  de  ces  solutions.  Les 
flagons  doivent  etre  conserve's  au  frais  et  a  I'obscurit6.  En 
prelevant  dans  les  flagons  les  doses  a  injecter,  il  faut  op6rer 
aussi  aseptiquement  que  possible  afin  de  ne  souiller  ni  le 
bouchon,  ni  le  liquide.  La  tuberculine  doit  rester  limpide. 
Une  fois  contamine'e,  elle  devient  trouble  et  n'est  alors  plus 
ultilisable.  La  seringue  sera  ste'rilise'e  de  pre'fe'rence  par  cuisson 
dans  1'eau,  sans  adjonction  d'antiseptiques  ou  d'alcalins. 
II  y  a  avantage  a  se  servir  d'une  aiguille  en  platine,  qu'il  suffit 
de  flamber  avant  chaque  injection. 

Nous  renvoyons  le  lecteur  au  travail  du  P'  Dr.  Sahli,  l 
pour  ce  qui  concerne  le  mode  d'emploi  de  la  tuberculine  B6ra- 
neck  dans  toutes  les  formes  de  tuberculoses  internes,  et  au 
travail  du  Dr.  de  Coulon,2  pour  ce  qui  concerne  les  tubercu- 
loses chirurgicales. 

Modes  d'emploi  dans  le  lupus  vulgaris:  Sur  les  conseils 
du  P-  Beraneck  nous  avons  fait  d'emble"e  des  injections  intra- 

>  Prof.  Dr.  Sahli.     "  Uber  Tuberkulin  behandlung." 

2  Dr.  de  Coulon  in  Revue  Medicale  de  la  Suisse  Romande,  n°  6,  juin,  1907. 


64  SIXTH  INTERNATIONAL 

focales,  c'est-a-dire,  que  nous  avons  injecte"  la  tuberculine  en 
plein  tissu  lupique.  L'auscultation  nous  ayant  reVele"  chez 
nos  malades,  1'absence  de  lesions  pulmonaires,  nous  avons 
commenc6  par  la  solution  -j-  que  nous  avons  injecte"  par 
i-io  de  cc.  trois  fois  par  semaine,  en  augmentant  la  quantite" 
de  tuberculine  de  -fa  de  cc.  k  chaque  piqure.  Parvenu  k 
•£-§•  de  cc.  de  la  solution  -g-  nous  passons  a  la  solution  -j-  que 
nous  injections  de  la  me'me  fagon,  puis  aux  solutions  -|-;  A,  B, 
C,  D,  etc.  Comme  on  le  verra  dans  les  observations  qui  suivent, 
il  n'est  pas  ne*cessaire  d'injecter  toute  la  gamme  des  solutions 
de  tuberculine. 

Les  injections  sont  indolores.  Elles  ne  produisent  pas,  en 
regie  ge"ne"rale,  de  reaction  locale  inflammatoire.  Nous  avons 
observe"  quelquefois  une  induration  au  siege  de  1'injection, 
lors  de  1'emploi  des  solutions  fortes  D,  E,  par  exemple,  in- 
duration qui  persiste  dix  k  huit  jours,  puis  disparait  sans  laisser 
de  trace. 

Nous  n'avons  jamais  observe"  d'eleVation  de  la  temperature 
pendant  1'emploi  des  solutions  ~  a  A.  Pendant  1'emploi 
de  la  solution  B  une  malade  a  pre"sente"  le  soir  et  le  lendemain 
de  la  piqure,  une  assez  forte  reaction  febrile  (voir  obs.  I.), 
reaction  passagere,  qui  ne  s'est  pas  reproduite  avec  les  injections 
de  solutions  plus  concentre"es  C,  D,  et  E. 

Nous  avons  observe"  quelquefois  egalement,  des  reactions 
f^briles  pendant  1'emploi  des  solutions  fortes  (B,  C,  D,  p.  ex.) 
lorsque  le  traitement  avait  e"te"  momentane"ment  interrompu. 
Exemple:  une  malade  en  est  k  -fa  de  la  solution  B.  Au  lieu 
de  revenir  deux  ou  trois  jours  apres,  recevoir  -fa,  elle  ne 
revient  que  quinze  jours  apres.  On  reprend  le  traitement 
avec  fa  de  la  solution  B.  Le  soir  me'me  et  le  lendemain 
reaction  locale  et  fievre.  Le  surlendemain  injection  de  -fa,  pas 
de  reaction  thermique.  Les  injections  se  font  des  lors  re"guliere- 
ment,  et  Ton  n'observe  plus  d'eleVation  de  temperature. 

Nous  n'avons  jamais  observe  d'autres  phe"nomenes  reac- 
tionnels.  Pour  nos  trois  malades,  le  traitement  a  6t6  am- 
bulatoire  du  commencement  a  la  fin. 

OBSERVATION  I. — Mme  D.,  40  ans.     Lupus  vulgaris  envahis- 


DERMATOLOGICAL   CONGRESS  65 

sant  toute  la  joue  et  1'oreille  gauche,  ayant  debute"  il  y  a  sept 
ans  au  lobule  de  1'oreille.  II  y  a  six  ans,  excision  du  lobule 
de  1'oreille,  operation  rapidement  suivie  de  r6cidive,  dans 
la  cicatrice,  le  lupus  envahit  peu  a  peu  le  pavilion  de  1'oreille 
puis  la  joue.  L'etat  general  de  la  malade  est  excellent. 

Debut  du  traitement  par  la  tuberculine  de  B6raneck,  le  22 
juin  1906.  Solution  ~;  ~;  ^-  et  A,  une  injection  tous  les 
deux  jours,  gu^rison  apparente  extraordinairement  rapide, 
puis  solution  B,  une  injection  deux  fois  par  semaine. 

Le  19  de"cembre  la  malade  est  blanchie. 

En  feVrier  1907,  cinq  petits  tubercules  r£apparaissent 
diss^mine's  sur  la  belle  cicatrice  du  lupus.  On  reprend  les 
injections  d'emble'e  avec  la  tuberculine  B.  Apres  quatre  in- 
jections (soit  T^,  -£w,  •&,  ^,),  gueYison  (27  fe"rier  1907).  Le  19 
mars,  deuxi6me  recidive;  sept  a  huit  petits  tubercules,  dont 
deux  sont  manifestement  ulce're's,  ont  re"apparu.  Nous  reprenons 
les  injections  avec  la  solution  B,  mais  avec  1'intention  bien 
arr£tee  cette  fois,  de  poursuivre  le  traitement.  La  quatrieme, 
cinquieme  et  dixieme  injection  de  la  solution  B,  sont  suivies 
d'elevations  de  la  temperature  (38°,  38.5°).  Les  tubercules 
ayant  disparu,  et  l'e"tat  ge"ne"ral  etant  excellent,  nous  continuons 
les  injections  en  employant  successivement  les  solutions  C, 
D,  E,  mais  en  ne  faisant  que  deux  injections  par  semaine. 
La  malade  est  gue"rie  depuis  le  mois  d'avril.  (V.  les  deux 
planches  I  et  II,  avant  et  apres  le  traitement.) 

OBSERVATION  II. — Mile.  L.,  25  ans.  Lupus  exedens  du 
lobe  de  i'oreille  gauche,  et  du  sillon  retro-auriculaire,  ayant 
apparu  il  y  a  trois  ans. 

Traitement  ante"rieur  a  la  tuberculine  pour  ainsi  dire  nul 
(pommades !)  De"but  du  traitement  a  la  tuberculine  de  BeVaneck 
le  20  juillet  1906. 

Solutions:  ^-;  -^;  -|-;  A.  Le  20  octobre,  la  malade  est 
blanchie.  A  partir  de  cette  date  au  ler  Janvier  1907  nous  fai- 
sons  encore  une  a  deux  fois  par  semaine,  une  s6rie  d'injections 
avec  la  solution  B  et  C. 

La  malade  est  gu6rie  depuis  le  mois  d'octobre  1906. 

OBSERVATION  III. — Madame  M.  40  ans.  Coxalgie  a  1'age 
de  1 6  ans.  Actuellement  ankylose"e  de  la  hanche  droite. 

VOL.    I. — 5 


66          SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

Lupus  vulgaire  de  la  face  (nez  et  joues),  apparu  il  y  a  vingt  ans 
au  moins.  Traitement  ant6rieur  aussi  multiples  qu'irr6guliers. 
Du  16  mai  1905  au  ler  juillet  1906,  nous  avons  trait<§ 
la  malade  par  la  radiotherapie.  Traitement  extre'mement 
long  vn  la  grande  surface  de  peau  malade  et  les  r6cidives 
survenues  pendant  ce  traitement,  mais  sornnie  toute  couronn^ 
d'un  assez  bon  r6sultat.  En  juillet  1906,  nouvelle  Eruption 
de  tubercules  sur  les  deux  pommettes  et  le  nez.  La  malade 
ayant  eu  deja  un  nombre  considerable  de  stances  de  rayon  X 
et  la  peau  des  pommettes  ayant  6t6  le  siege  de  radiodermites 
provoque'es  successives,  nous  nous  d6cidons  a  traiter  la  malade 
par  des  injections  de  tuberculine  Beraneck.  Apres  une  seYie 
d' injections  avec  la  solution  A,  soit  trois  semaines  apres  le 
d6but  du  traitement,  tous  les  tubercules  avaient  disparus. 
Nous  avons  fait  encore  une  deuxieme  s£rie  d'injections  avec 
la  solution  B,  une  injection  deux  fois  par  semaine;  la  gu6rison 
qui  date  d'octobre  1906,  s'est  maintenue  jusqu'a  ce  jour.  La 
tuberculine  a  6t&  d'un  pre"cieux  secours  dans  ce  cas,  car  nous 
d6sesperions  d'obtenir  un  r6sultat  definitif  avec  les  rayons  X. 
(V.  les  deux  planches  III  et  IV,  avant  et  apres  le  traitement.) 

CONCLUSION 

Le  nombre  de  cas  que  nous  avons  trait6  par  la  tuberculine 
B£raneck  est  insuffisant  pour  nous  permettre  d'en  d6duire  des 
conclusions  precises,  et  de  prdner  la  spe"cificit6  de  ce  nouveau 
traitement.  II  est  cependant  suffisant  pour  nous  permettre 
d'en  recommander  1'emploi,  e"tant  donne1  les  re"sultats  que 
nous  avons  obtenus.  A  cet  £gard,  la  mat6rialit6  des  faits  qui 
font  1'objet  de  ce  travail  est  inde"niable. 


PLANCHE  I — Illustration  pour  1'  article  du  Dr.  Lassueur. 


PLANCHE  II — Illustration  pour  1'  article  du  Dr.  Lassueur. 


PLANCHE  III— Illustration  pour  1'  article  du  Dr.  Lassueur. 


PLANCHE  IV— Illustration  pour  1'  article  du  Dr.  Lassueur. 


LA    TUBERCULOSE     DE     LA    PEAU     DANS    LA 
VILLE  DE  MEXICO 

PAR   M.  LE    PROFESSEUR  JESUS    GONZALEZ   URUENA,  MEXICO 

Les  observations  pratiques  pendant  tm  peu  plus  de  deux 
ans  dans  la  section  des  maladies  cutan^es  et  syphilitiques 
du  "Consultorio  Central"  de  la  Capitale  du  Mexique  ont  servi 
de  base  a  la  pre"sente  communication. 

Parmi  5268  malades  de  la  peau  qui  ont  et6  soigne"s  du 
7  feVrier  1905  au  20  avril  1907,  il  y  a  eu  46  cas  de  tuberculose 
cutanee,  repartis  de  la  maniere  suivante : 

Gommes  tuberculeuses 19 

Lupus  e'rythemateux 1 1 

Lupus  tuberculeux  plan 7 

Ulce'rations  tuberculeuses 3 

Lupus  pernio 2 

Tuberculose  verruqueuse 2 

Ade"nite  tuberculeuse 2 

Ceci  donne  comme  resultat  8.73  pour  mille  de  tuberculeux 
cutane"s  sur  le  nombre  total  des  maladies  de  la  peau  observers 
pendant  ce  temps. 

GOMMES    TUBERCULEUSES 

Cette  forme  est  la  plus  fre'quente  et  repre"sente  3.6  pour 
mille  de  1'ensemble  des  patients  note's.  Le  siege  de  pre"- 
dilection  fut  le  cou,  ou  Ton  observa  14  cas.  Tous  les  malades 
6taient  des  adultes,  a  1'exception  de  quatre,  age's  de  3,  5,  6  et 
7  ans  respectivement.  Parmi  les  individus  atteints  de  cette 
maladie,  13  appartenaient  au  sexe  masculin  et  6  au  sexe 
fe"rninin.  Les  occupations  de  ces  individus  e"tant  tres  varies, 
ne  present  a  aucune  consideration  g6n6rale. 

On  ne  fait  pas  mention  dans  les  registres  s'il  s'agit  de  la  va- 
rie"t6  gommeuse  dermique  ou  bien  de  la  vari6t6  hypodermique, 

67 


68     v  SIXTH   INTERNATIONAL 

ce  que,  d'ailleurs,  il  aurait  e"te"  impossible  de  pr£ciser  dans 
plusieurs  cas,  si  Ton  songe  a  la  p&riode  avanc6e  devolution 
oil  se  trouvaient  les  patients. 

LUPUS    ERYTHEMATEUX 

A  ce  type  morbide  correspondent  n  cas,  parmi  les  46  de 
lesions  tuberculeuses  observes,  ce  qui  donne  2  pour  mille  sur 
la  totality  des  malades. 

Conforme'ment  aux  observations  recueillies  dans  differ- 
ents  pays,  le  siege  de  predilection  de  la  maladie  etait  le  visage, 
puisque  c'est  Ik  qu'elle  apparut  chez  les  n  patients  enregis- 
tres.  Les  femmes  fournirent  un  plus  grand  contingent  que  les 
hommes  (9  centre  2).  Tous  les  malades  6taient  adultes,  leurs 
ages  etant  compris  entre  19  et  43  ans.  Le  lupus  e"rythemateux 
est  rare  avant  1'age  de  17  ans. 

Parmi  les  hommes  et  les  femmes  atteints,  plusieurs  exer- 
gaient  un  metier  pre"disposant  k  la  congestion  faciale:  on  y 
trouvait  des  repasseuses,  des  cuisinieres,  des  couturieres,  des 
relieurs,  etc.  L'influence  de  cette  perturbation  circulatoire 
locale  sur  le  developpement  de  la  dermatose  est  bien  connue. 

Aucun  des  cas  observes  ne  de"passa  les  formes  ordinaires 
de  cette  vari^te"  de  lupus,  et,  d'apres  le  souvenir  personnel 
que  nous  en  gardons,  ils  appartenaient,  pour  la  plupart,  a 
celui  qu'on  appelle  fixe,  et  quelques  uns  a  I'erytheme  centri- 
fuge de  Brocq,  ou  Ton  a  toujours  remarqu6  le  tre"pied  symp- 
tomatique  caracteristique :  phenomenes  vasculo-conjonctifs, 
e*pitheliaux  et  de  regression  consecutive. 

Des  recherches  n'ont  malheureusement  pas  ete  faites  parmi 
les  sujets  qui  figurent  dans  notre  statistique,  dans  le  but 
d'apporter  quelque  lumiere  sur  la  nature  de  ce  lupus.  Nous 
dirons  seulement  que,  parmi  les  cas  que  nous  sont  personnels, 
nous  avons  trouv6,  k  1'instar  de  Boeck,  la  tuberculose  chez  les 
proches  parents  de  1'individu  atteint  du  lupus  e"rythemateux. 

II  est  tres  important  de  faire  remarquer  qu'k  Mexico,  ville 
qui  jouit  d'un  climat  d'altitude  (2262  metres  au-dessus  de  la 
mer),  et  qui  possede  un  ciel  presque  toujours  bleu,  un  soleil 
brillant  et  une  population  peu  dense,  le  lupus  eYythemateux, 
tuberculose  certainement  att6nu£e  si  meme  c'est  une  tuber- 
culose est  beaucoup  plus  frequent  que  le  lupus  vulgaire,  dont 


DERMATOLOGICAL  CONGRESS  69 

la  virulence  bacillaire  est  notoire.  II  n'est  pas  a  notre  con- 
naissance  de  statistique  compared  de  la  frequence  relative  des 
deux  formes  de  lupus  dans  aucun  pays  du  monde;  mais  il 
suffit  d'avoir  visite"  I'Hopital  Saint-Louis  a  Paris  et  d'avoir 
assiste"  aux  consultations  dermatologiques  de  cette  me'tropole, 
pour  £tre  a  m£me  d'appre"cier  1'^norme  disproportion  qui 
existe  a  Paris  entre  la  frequence  du  lupus  vulgaire  et  celle 
du  lupus  ery  the~mateux ;  la  quantite"  d'individus  atteints  du 
premier  est  surprenante,  tandis  que  les  cas  du  second  sont 
rares.  La  densite"  de  la  population  parisienne,  le  peu 
d' elevation  de  la  ville  qui  se  trouve  presque  au  niveau  de 
la  mer,  ses  journe"es  si  souvent  nuageuses  et  si  courtes 
pendant  1'hiver,  tout  cela  n'exerce-t-il  pas  quelque  influence? 
Ce  renseignement  au  sujet  de  la  plus  grande  frequence 
du  lupus  erythe"mateux  a  Mexico  est  d'autant  plus  im- 
portant, que  Ton  affirme  que,  de  rne'me  que  pour  le  lupus 
vulgaire,  sa  frequence  diminue  a  mesure  que  Ton  approche  de 
1'Equateur,  et  que,  par  centre,  les  pays  septentrionaux  ou 
la  temperature  descend  facilement  au-dessous  de  15  degre"s 
et  ou  1'air  est  constamment  sature"  d'humidite",  sont  plus 
fortement  atteints. 

LUPUS  VULGAIRE 

Nous  avons  vu  7  cas  de  ce  type,  soit  1.33  pour  mille 
des  cas  dermatologiques  observes. 

La  lesion  si^geait  au  visage  dans  2  cas ;  dans  i  au  poignet ; 
dans  i  sur  la  cuisse,  et  dans  3  disse'mine's  sur  le  corps. 

Comme  d'habitude,  le  plus  grand  nombre  de  victimes  fut 
f ourni  par  les  femmes  (4  centre  3  hommes) . 

Les  registres  accusent  pour  ce  qui  concerne  1'age,  des  varia- 
tions entre  10  et  56  ans,  et  il  faut  remarquer  qu'il  n'y  a  eu  que 
deux  individus  dont  1'age  ait  de"passe"  38  ans,  ce  qui  confirme 
1'opinion  sur  1'apparition  de  la  maladie  pendant  la  jeunesse. 

Outre  le  peu  de  frequence  relative  de  cette  classe  de  lupus 
par  comparaison  avec  le  lupus  e'rythe'mateux,  il  est  a  remar- 
quer que  les  formes  ulce"reuses,  rongeuses,  voraces,  du  lupus 
vulgaire  sont  inconnues  parmi  les  malades  que  nous  citons. 
Les  7  cas  observes  appartiennent  tous  au  lupus  plan.  Dans 


70  SIXTH   INTERNATIONAL 

le  rapport  intitule1  "La  Lutte  centre  le  Lupus  vulgaire, "  pr6- 
sente"  par  Finsen  a  la  Conference  Internationale  centre  la  tuber- 
culose,  qui  se  r6unit  k  Berlin  en  1902,  il  est  not6  qu'il  y  avait 
au  Danemark  de  1.200  a  1.300  individus  atteints  du  lupus, 
c'est-k-dire,  a  peu  pres  0.6  pour  mille  de  la  population  totale. 
En  6tablissant,  pour  la  ville  de  Mexico,  une  proportion  analogue 
avec  les  renseignements  que  nous  posse'dons,  et  en  l'6tendant 
k  tous  les  habitants  du  District  fe'de'ral  qui  fournissent  le 
contingent  de  la  consultation  dermatologique,  Ton  obtient 
un  chiffre  de  beaucoup  inf6rieur  a  celui  qui  a  6t6  signa!6  par 
le  celebre  me'decin  Danois,  puisqu'il  s'eleve,  approximativement, 
k  o.i  pour  mille  du  nombre  des  habitants.  Nous  ignorons  si 
dans  les  autres  pays  on  a  6tabli  une  statistique  proportionnelle 
semblable  pour  le  lupus  vulgaire. 

ULCERATIONS  TUBERCULEUSES 

Nous  n'avons  que  3  observations  se  rapportant  k  cette 
vari6te  de  tuberculose  cutan£e,  laquelle  apparut  deux  fois  sur 
le  visage  et  une  fois  sur  le  cou,  rev^tant,  chez  un  des  individus 
atteints  sur  la  premiere  region,  la  forme  serpigineuse.  Cela 
nous  donne  k  peine  0.56  pour  mille  sur  le  total  des  malades, 
ce  qui  confirme  1'opinion  accepted  que  les  ulce>ations  tuber- 
culeuses  de  la  peau  sont  des  lesions  tres  peu  communes. 
Vallas,  dans  sa  these,  ne  parvint  k  r£unir  que  35  observations. 
Quoique  rare,  1'existence  de  cette  lesion  comme  manifestation 
premiere  de  la  bacillose  est  hors  de  doute;  cependant,  le 
plus  souvent  elle  est  regarded  comme  une  complication  des 
tuberculoses  des  visceres,  de  la  tuberculose  pulmonaire  en 
particulier,  surtout  k  la  p£riode  cachectique. 

II  nous  est  impossible  de  fixer  ce  point  d'une  facon  certaine 
chez  nos  malades,  faute  de  renseignements  explicites;  mais  il 
est  k  supposer  qu'ils  ne  presentaient  pas  de  symptdmes  mar- 
que's d'un  autre  mal,  les  registres  ne  portant  aucune  indication 
k  ce  sujet. 

LUPUS    PERNIO 

Cette  dermatose  Strange  et  singuliere  fut  observed  aux 
oreilles  chez  deux  hommes  age's  de  36  et  32  ans  respectivement. 


DERMATOLOGICAL   CONGRESS  71 

TUBERCULOSE    VERRUQUEUSE 

Deux  individus  furent  atteints  de  cette  autre  varie*t6  de 
lupus,  caracte'rise'e  par  son  apparence  morphologique  ver- 
ruqueuse,  papillomateuse ;  mais  dont  la  structure  histologique 
est  identique  a  celle  des  autres  lesions  lupiques  et  qui  recon- 
naissent  la  m£me  6tiologie  et  pathoge"nie:  1'inoculation  du 
bacille  de  Koch. 

La  maladie  ne  se  localisa  point,  chez  les  deux  patients, 
sur  le  dos  de  la  main  ni  du  poignet,  sieges  considers  comme 
classiques;  chez  1'un  d'eux,  elle  apparut  a  1'aine,  et  sur 
le  cou  chez  1'autre.  L'un  des  malades  6tait  manoeuvre,  et 
1'autre  macon,  metiers  qui  ne  pre"disposent  pas,  par  eux-meTnes, 
a  la  tuberculose  verruqueuse,  celle-ci  e"tant  1'apanage  d'in- 
dividus  qui  sont  exposes  au  contact  des  tuberculeux  ou  de 
leurs  expectorations. 

ADENITE    TUBERCULEUSE 

Nous  n'avons  rien  de  particulier  a  dire  sur  cette  lesion 
qui  de" passe  presque  le  domaine  dermatologique,  et  qui,  depuis 
longtemps,  est  bien  connue  et  etudie'e.  Dans  les  deux  cas 
observes,  elle  apparut  sur  le  cou  de  deux  jeunes  gens,  1'un 
appartenant  au  sexe  masculin  et  1'autre  au  sexe  fe"minin,  age's 
de  21  et  22  ans  respectivement. 

En  re'sume',  il  y  a  deux  points  dignes  de  remarque  dans 
tout  ce  qui  precede:  le  premier,  ce  sont,  appuyes  sur  de 
nombreux  chiffres,  les  particularity  que  presentent,  dans  la 
ville  de  Mexico,  des  affections  aussi  importantes  que  les  tuber- 
culoses de  la  peau ;  le  second,  d'un  plus  grand  inte"r£t  peut-£tre, 
vu  son  importance  pratique,  se  rapporte  aux  donn6es  qui 
peuvent  e'tre  mises  a  profit  pour  preVenir  le  deVeloppement 
d'un  des  plus  grands  fl^aux  qui  affligent  rhumanite":  la  tuber- 
culose. Ce  dernier  point  est  digne  de  toute  attention,  si  Ton 
remarque  que  dans  les  campagnes  entreprises  dans  presque 
tous  les  pays  centre  cette  maladie,  Ton  ne  tient  pas  compte, 
pour  sa  prophylaxie,  du  facteur  cutane*.  Si  nous  voulons  que 
notre  travail  au  profit  d'un  ide"al  aussi  grandiose  soit  complet, 
il  faudra  agir,  a  1'avenir,  de  la  mSme  fagon  que  pour  la  tuber- 
culose pulmonaire,  car,  si  cette  derniere  maladie  est  plus 


72  SIXTH  INTERNATIONAL 

fr£quente  et  plus  virulente  que  les  tuberculoses  cutane"es,  elle 
est,  par  centre,  mieux  connue  du  public,  qui  n'a  pas  meme  6te 
avert!  des  dangers  que  peut  presenter  1'  infection  tuberculeuse 
par  la  peau. 

Notre  plus  grand  souhait  est  que  le  VIs.  Congres  de  Der- 
matologie  veuille  bien  recommander  ce  point  a  la  consideration 
des  Ligues  Internationales  Anti-tuberculeuses. 

CONTRIBUTION  ON  THE  NATURE  AND  TREAT- 
MENT OF  LUPUS  ERYTHEMATODES 

BY  PROF.  ROBERT  CAMPANA  AND  DR.  G.  LANZI,  OF  ROME 

Dr.  Lanzi,  a  young  student  of  mine  in  the  Clinic,  has  ad- 
vanced an  etiological  theory  for  lupus  erythematodes.  I  had 
taught  that  in  lupus  erythematodes  conditions  of  different 
predispositions,  due  to  chronic  infections,  may  occur  together 
and  constitute  a  great  part  of  the  cause  of  the  disease. 

With  this  opinion,  based  upon  numerous  clinical  observa- 
tions, I  now  believe  myself  justified  in  affirming  a  useful 
therapeutic  principle,  which,  if  it  has  not  the  extensive 
application  of  the  above-mentioned  etiological  idea,  has  cer- 
tainly the  merit  of  practicability  and  considerable  foundation 
in  experience. 

To  enable  those  who  do  not  occupy  themselves  with  this 
special  subject  to  appreciate  the  importance  of  the  matter, 
I  will  recall  to  them,  or  will  inform  them  of,  a  few  well-known 
and  undisputed  facts  concerning  lupus  erythematodes.  They 
are: 

1.  That  lupus  erythematodes  often  becomes  an  incurable 
disease  under  the  treatment  at  present  generally  used. 

2.  That  there  are  cases  of  lupus  erythematodes  in  which 
tuberculin  acts  in  the  same  way  as  it  does  in  true  lupus. 

3.  That  there  are  some  cases  not  cured  under  the  most 
active   surgical   treatment   but   afterwards   cured   with   sur- 
prising ease  by  the  use  of  mercurial  ointment,  recommended 
by  Hebra  as  most  efficacious,   and  yet  in  many  instances 
not  proving  so  in  practice. 

So  much  premised,  it  will  be  understood  that  therapeutical 


DERMATOLOGICAL  CONGRESS  73 

action,  in  such  cases,  must  be  guided  by  an  analysis  of  the 
conditions  above  alluded  to,  in  order  to  distinguish  the  special 
peculiarities  forming  the  basis  of  the  disease  in  each  case. 
To  begin  with  the  injection  of  tuberculin  and  to  get  no  local 
or  general  reaction  certainly  would  assign  to  the  case  a  basis 
quite  other  than  the  tuberculous  predisposition  accepted  by 
many,  but  not  admitted  by  all,  in  lupus  erythematodes. 

To  begin  with  local  and  general  treatment  with  mercury 
and  have  no  apparent  improvement  therefrom  certainly 
would  not  predispose  one  to  continue  this  method  of  treatment. 
If,  however,  without  these  precautions  we  proceeded  by  an 
inverse  method,  or  were  guided  by  the  single  case,  we  might 
have  very  bad  results. 

Where  mercury  has  failed  to  produce  a  beneficial  result 
and  tuberculin  has  given  one,  local  surgical  treatment  is 
possible.  Where  the  contrary  happens  and  the  physician 
in  charge  of  the  case  has  not  attempted  precautionary  tests, 
local  treatment  is  injurious,  disastrous. 

I  know  of  more  than  one  case  which  had  been  treated  for 
a  long  time  by  curettage  and  caustics  without  result;  but 
when  I  suspended  these  methods  and  applied  mercurial  oint- 
ment a  cure  followed. 

As  also  in  cases  in  which  the  phenomenon  was  of  tuberculous 
nature,  the  caustic  has  arrested  the  process,  and  often  pre- 
vented any  fresh  return. 

My  conclusion,  then,  is  this:  that  we  may  go  wrong  with 
these  old  means  and  methods  if  we  are  guided  only  by  the 
idea  that  mercury  as  well  as  curettage  has  proved  beneficial 
in  the  treatment  of  lupus,  without  discriminating  when  and 
why.  On  the  other  hand,  distinguishing  properly,  according 
to  the  basis  of  the  etiological  predisposition,  we  can  proceed 
to  operate  or  to  apply  mercury  with  evident  and  precise 
reasons,  differing  for  each  case. 

A  third  remedy  has  been  recently  mentioned  by  many 
English  and  American  specialists  (Fox,  Jackson  and 
Lustgarten) — namely,  small  continued  doses  of  sulphate  of 
quinine.  This  would  lead  one  to  suppose  that  malaria  or 
conditions  resulting  from  malaria  might  in  some  cases  be  the 
predisposing  cause  of  the  disease. 


74  SIXTH  INTERNATIONAL 

The  introduction  of  this  new  predisposing  cause  does  not 
refute  the  theory  we  advance,  but  simply  advises  that  this 
other  variety  be  kept  in  mind,  though  certainly  not  of  as 
frequent  occurrence,  numerically,  as  the  other  two. 

Discussion 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  said  that  in  the  paper  read 
by  Prof.  Campana  and  Dr.  Lanzi  two  classes  of  cases  were  men- 
tioned, one  in  which  the  tuberculin  reaction  was  obtained,  and 
the  other  in  which  it  was  not  obtained,  and  he  asked  in  what 
proportion  of  cases  in  which  the  tuberculin  was  given  the  reaction 
followed. 

PROF.  CAMPANA  replied  that  the  reaction  was  obtained  in  from 
seventy -five  to  ninety  per  cent,  of  the  cases. 

DR.  JAY  F.  SCHAMBERG,  of  Philadelphia,  said  he  was  interested 
in  the  use  of  tuberculin  in  lupus  erythematosus,  particularly  as  he 
had  recently  used  it  in  one  case  on  purely  experimental  grounds. 
The  patient  was  a  colored  woman  with  an  extensive  lupus  ery- 
thematosus of  twelve  years'  standing,  with  considerable  loss  of 
pigment  over  the  patch.  She  had  received  six  injections  of  tuber- 
culin T.  R.,  in  doses  ranging  from  i :  1800  to  i :  1000  of  a  milligram. 
On  at  least  one  occasion  following  the  injection  there  was  a  dis- 
tinct febrile  reaction,  with  sweating  and  malaise.  The  exact 
temperature  elevation  was  not  ascertained.  A  local  reaction  in 
the  diseased  area  also  occurred.  Prior  to  the  institution  of  the 
tuberculin  treatment,  the  parts  were  distinctly  whitish,  while  now 
they  have  taken  on  a  decided  redness,  and  the  small  islets  of 
pigmentation  seem  to  be  increasing  in  size. 

DR.  MILTON  B.  HARTZELL,  of  Philadelphia,  confessed  to  a  certain 
degree  of  surprise  at  the  large  proportion  of  cases  of  lupus  ery- 
thematosus in  which  Prof.  Campana  was  able  to  obtain  a  reaction 
after  the  injection  of  tuberculin.  Certainly  this  was  not  in  accord 
with  the  experience  of  a  vast  number  of  dermatologists.  There 
were  a  certain  number  of  cases  of  lupus  erythematosus  in  which 
it  was  difficult  to  make  the  differential  diagnosis  between  that 
affection  and  lupus  vulgaris,  and  it  was  quite  possible  that  a  large 
proportion  of  the  cases  in  which  the  reaction  was  obtained  were 
in  fact  lupus  vulgaris  rather  than  lupus  erythematosus. 

As  to  the  results  of  treatment  of  lupus  erythematosus,  every  one 
was  well  aware  of  the  fact  that  this  was  a  very  capricious  disease, 


DERMATOLOGICAL   CONGRESS  75 

and  that  in  the  early  stages  spontaneous  involution  of  the  patches 
might  occur  no  matter  what  the  treatment  had  been.  It  was 
therefore  difficult  to  judge  the  exact  value  of  this  or  that  remedy. 
In  regard  to  the  malarial  element  which  was  referred  to  by  the 
authors  of  the  paper,  Dr.  Hartzell  said  he  did  not  think  the  con- 
clusion drawn  regarding  it  was  justified.  We  knew  that  quinine 
had  other  effects  than  its  destructive  action  on  the  plasmodium 
malariae,  and  whatever  good  effects  quinine  exerted  in  this  disease 
were  certainly  not  due  to  its  action  on  the  plasmodium,  but  on  the 
circulatory  system  itself.  The  speaker  said  he  had  tried  quinine 
very  extensively  in  these  cases,  and  while  he  had  seen  improve- 
ment follow  its  use,  he  had  never  seen  it  effect  a  cure. 

DR.  STOPFORD  TAYLOR,  of  Liverpool,  said  the  remedy  in  the 
treatment  of  lupus  erythematosus  which  had  proved  most  suc- 
cessful in  his  hands  was  pyrogallic  acid.  In  the  common  or  sta- 
tionary types  of  the  disease  he  used  a  ten  per  cent,  ointment  of 
pyrogallic  acid  in  the  same  way  as  he  used  it  in  lupus  vulgaris. 
In  one  case  of  acute  lupus  erythematosus  supervening  on  a  chronic 
condition,  the  disease  had  been  brought  to  a  successful  issue  with 
two  per  cent,  of  the  acid,  combined  with  Lassar's  paste  as  a  base. 
We  knew  that  pyrogallic  acid  became  oxidized  on  exposure  to  the 
air,  and  it  was  probable  that  further  oxidation  took  place  when 
it  was  mixed  with  the  zinc  oxide  in  the  paste,  thus  converting 
the  caustic  action  of  the  acid  into  a  sedative  (pyraloxin) ;  and 
further,  that  it  also  de-oxidized  the  inflamed  tissues  to  which  it 
was  applied. 

DR.  SAMUEL  SHERWELL,  of  Brooklyn,  said  that  in  cases  of  lupus 
erythematosus  where  the  mucous  membranes  were  not  involved 
he  had  almost  invariably  obtained  excellent  results  by  the  use  of 
the  curette,  followed  by  the  application  of  the  acid  nitrate  of 
mercury. 

DR.  HERMAN  LAWRENCE,  of  Melbourne,  Australia,  asked  whether 
the  reaction  in  the  twenty  per  cent,  of  cases  of  lupus  erythematosus 
after  the  injection  of  tuberculin  was  really  definite,  or  whether 
the  patients  simply  complained  of  certain  symptoms.  The  speaker 
said  he  would  like  to  refer  to  a  very  successful  and  effective  method 
of  treatment  of  chronic  lupus  erythematosus  which  he  reported 
some  time  ago  in  the  British  Medical  Journal.  The  treatment 
consisted  of  scarification,  followed  by  rubbing  in  iodoform,  and 
then  the  application  of  a  waxed  indiarubber  pad  at  moderate 
pressure,  which  was  kept  up  for  twenty-four  or  forty-eight  hours. 


NOUVELLES    RECHERCHES   SUR    L'ECZEMA 
PAPULO-VESICULEUX 

PAR  LE  DOCTEUR  L.  BROCQ  ET  LE  DOCTEUR  G.  AYRIGNAC,  PARIS 

Resume: 

Nous  r6servons  le  nom  d'ecz6ma  papulo-vesiculeux  a  une 
forme  morbide  caracterisee  au  point  de  vue  object  if  et  comme 
16sion  elementaire  initiale  par  une  papulo-v6sicule  petite,  mais 
des  plus  nettes  aux  endroits  ou  elle  se  forme  sur  la  peau  saine. 
Elle  est  compose'e:  (a)  d'une  base  rose"e  arrondie,  legerement 
surelevee,  donnant  au  frolement  du  doigt  la  sensation  d'une 
petite  saillie,  disparaissant  en  grande  partie  par  la  pression, 
ce  qui  montre  que  sa  rougeur  est  surtout  congestive ;  (6)  d'une 
partie  centrale  nettement  constitute  par  une  vesicule  fragile 
qui,  ou  bien  est  excori6e  par  le  grattage  et  donne  naissance  a 
une  croutelle  noiratre,  ou  bien  se  de'chire,  soit  spontanement, 
soit  sous  le  moindre  traumatisme,  et  laisse  ecouler  une  se'rosite' 
citrine  analogue  a  celle  de  I'ecz^ma  vulgaire. 

Un  autre  fait  capital  qui  domine  1'histoire  de  1' eczema 
papulo-vesiculeux,  c'est  qu'en  un  point  quelconque  du  corps, 
presque  tou jours  aux  jambes,  ou  aux  bras,  ou  sur  les  pieds, 
ou  sur  la  face  dorsale  des  mains  vers  les  poignets,  on  peut 
trouver  un  placard  6ruptif  presentant  1'aspect  ordinaire  de 
1'eczema  vulgaire ;  cependant,  a  son  niveau,  la  peau  est  comme 
e"paissie,  profonde'ment  enflammee,  excorie'e,  ce  qui  semble 
prouver  que  les  elements  constitutifs  primordiaux  ont  ete  des 
papulo-vesicules. 

L'eruption  de  1'eczema  papulo-vesiculeux  est  presque  tou- 
jours  abondante,  diffuse,  syme'trique;  assez  sou  vent  elle  a  une 
tendance  marquee  a  se  gene"raliser.  Elle  eVolue  par  poussees 
successives  dont  la  cause  pro  vocat  rice  est  variable,  sou  vent 
impossible  a  saisir  au  premier  abord.  Les  poussees  peuvent 
£tre  subintrantes  et  constituer  ainsi  des  periodes  plus  ou 
moins  longues  de  crise,  ou  bien  etre  s6parees  par  des  periodes 
de  repos  complet. 

76 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS  77 

Cette  forme  eruptive  est  e'minemment  prurigineuse. 
Elle  a,  au  point  de  vue  objectif,  les  rapports  les  plus  etroits 
avec: 

1.  Le  prurigo  simplex,  qui  en  differe  en  ce  que  les  elements 
eruptifs  sont  plus  franchement  urticariens,  souvent  plus  volu- 
mineux,  un  peu  moins  nettement  vesiculeux,  et  surtout  en  ce 
qu'on  n'y  observe  ni  placards  nets  d'ecze'ma,  ni  lichenification. 

2.  Le  prurigo  de  Hebra,  qui  en  differe  par  sa  longue  duree, 
sa  tenacite,  ses  localisations  si  sp6ciales,  sa  tendance  si  mar- 
quee aux  lichenifications,  etc. 

II  est  certain  que  I'ecz6ma  papulo-v6siculeux  offre  les  plus 
grandes  affinites  avec  le  groupe  des  prurigos:  il  constitue  un 
trait  d'union  entre  I'ecz6ma  vesiculeux  vrai  d'une  part  et  les 
prurigos  d'autre  part. 

Nous  avions  depuis  longtemps  6tabli,  en  nous  fondant  sur 
1'analyse  des  faits  cliniques,  que,  tandis  que  les  irritations 
artificielles  d'origine  externe  et  que  le  microbisme  banal  de  la 
peau  jouent  un  role  des  plus  considerables  dans  l'6tiologie  et 
la  pathogenic  de  1' eczema  vesiculeux  vrai,  ce  sont  les  in- 
toxications accidentelles,  les  auto-intoxications,  les  6branle- 
ments  subis  par  le  systeme  nerveux  qui  jouent  le  rdle  majeur 
dans  la  genese  de  1'eczema  papulo-v6siculeux. 

Nous  avons  6tudie  cliniquement  ce  point  special,  et  re- 
cherche quel  est  l'6tat  de  la  nutrition  chez  les  sujets  atteints 
d'ecz6ma  papulo-v6siculeux. 

Nous  avons  choisi  pour  cela  quatorze  malades  soigneuse- 
ment  diagnostiqu6s,  chez  lesquels  le  type  6ruptif  6tait  d'une 
parfaite  purete.  Nous  avons  effectue"  chez  eux  300  analyses 
d'urine  en  s6rie.  Tous  ces  malades  avaient  et6  soumis  k  un 
regime  rigoureusement  determine^  et  leurs  coefficients  urolo- 
giques  ont  et6  rapportes  aux  coefficients  normaux  pour  chaque 
regime  (voir  nos  travaux  anterieurs). 

Les  deux  constatations  les  plus  importantes  qui  d6coulent 
de  ces  recherches  sont  les  suivantes: 

1.  Dans  80  %  cas,  il  y  avait  diminution  notable  de  la 
perm6abilit6  r^nale. 

2.  Dans  90  %  des  cas,  il  y  avait  augmentation,  parfois 
considerable,  des  fermentations  intestinales. 


ROSACEA:  HISTORISCH,   KLINISCH   UND 
THERAPEUTISCH 

VON  DR.  P.  G.  UNNA,  HAMBURG 

Die  meisten  Leser  werden  auf  der  Universitat,  in  Lehr- 
buchern  oder  Zeitschriften  als  wissenschaftliche  Benennung 
der  "roten  Nase"  oder  "Kupfernase"  nicht  das  im  Titel  an- 
gegebene  Wort:  Rosacea,  sondern  den  Doppelnamen :  "Acne 
rosacea"  gehort  haben — leider,  wie  ich  gleich  hinzufiigen 
muss.  Denn  wenn  irgendwo  eine  falsche,  irrtumliche  Benen- 
nung auf  die  Auffassung  einer  Krankheit  eine  hemmende  u. 
auf  ihre  Behandlung  eine  schadigende  Einwirkung  gehabt 
hat,  so  war  es  die  Klassification  der  "roten  Nase"  als:  Acne 
rosacea.  Grade  hundert  Jahre  hat  diese  von  Willan  (1757- 
1812)  u.  Bateman  (1778-1821) *  eingefiihrte  Bezeichnung  die 
Lehre  von  der  Rosacea  verwirrt,  u.  obwohl  alle  selbstandig 
denkenden  Dermatologen  in  dem  verflossenen  Jahrhundert 
gegen  die  Einreihung  der  Rosacea  in  das  Kapitel  der  Akne 
mehr  oder  minder  energischen  Protest  einlegten,  so  schleppt 
sich  die  sogenannte  "Acne  rosacea"  doch  noch  bis  in  die 
neuesten  Auflagen  der  meisten  heutigen  Lehrbiicher  fort. 
Es  ist  zu  hoffen,  dass  in  dem  neuen  Jahrhundert  dieser  Ana- 
chronismus  verschwindet  u.  einer  naturgemasseren  Auffassung 
der  Rosacea  Platz  macht. 

In  der  Tat  war  diese  Benennung  u.  Klassifikation  durch 
Willan  u.  seine  Nachfolger  ein  Ruckschritt  gegeniiber  der 
bis  dahin  bei  den  Schriftstellern  des  Mittelalters  u.  der  Neuzeit 
geltenden  Auffassung.  Bei  den  letzteren  (beispielsweise : 
A mbroise  Par£,  Joh.  Riolan,  Jr.,  Astruc,  Lorry,  Erasmus  Darwin, 
Plenck]  spielt  die  Affektion  unter  dem  Namen:  Gutta  rosea 

1  Willans  "Description  and  Treatment  of  Cutaneous  Diseases"  erschien 
unvollstSndig  in  Lieferungen  mit  Tafeln  von  1798-1807.  Die  Beschreibung 
der  Acne  rosacea  befindet  sich  erst  in  der  nach  Willans  Tode  von  Bateman 
herausgegebenen :  "Practical  Synopsis"  (1813)  u.  die  erste  Abbildung  in  dem 
Tafelwerk:  "Delineations  of  Cutaneous  Diseases"  (1815-1817). 

78 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS  79 

eine  ganz  selbstandige  Rolle.     Der  dieser  Affektion  in  Frank- 
reich  seit  alten  Zeiten  zukommende  populare  Name:  Coupe- 
rose  soil    (nach  Giber  f)    aus   Gutta   rosea  korrumpiert  sein. 
Plenck    (1738-1807)   nahm  diesen  nicht  prajudizierlichen  u. 
— als  roter  Tropfen,  roter  Fleck — ganz  bezeichnenden  Namen 
mit    der   auch   schon   fruher    gebrauchten,    leichten    Veran- 
derung:  Gutta  rosacea1  auf,  von  der  er  neun  Abarten  beschrieb, 
darunter  die  Gutta  rosacea  simplex  oenopotorum  u.  pernionalis. 
Wie  kam  nun  Willan  dazu,  den  von  Plenck  gebrauchten 
Namen :  Gutta  rosacea  in  Acne  rosacea  umzuwandeln  ?    |Be- 
kanntlich  hat  Willan  nach  dem  Vorgange  des  Budapester  Pro- 
fessors Plenck,  welcher  1780  sein  System  der  Hautkrankheiten 
publizierte  u.  die  aussere  Form  der  Ausschlage  zum  ersten 
Male  zum  Einteilungsprinzip  erhob,  die  Dermatosen  ebenfalls 
nach  der  ausseren  Form  in  acht  Ordnungen  gebracht :  Papulae, 
Squamae,    Exanthemata,    Bullae,    Pustulae,   Vesiculae,    Tuber- 
cula,   Maculae.      Die   ganze   Ordnung   der  Tubercula,   unter 
welche  Willan  die  Akne  einreihte,  fehlt  noch  bei  Plenck;  bei 
diesem  finden  sich  das  Tuberculum  und  die  Van   (Finnen) 
zusammen    in    der    Ordnung:     Papulae.       Willan   bedurfte, 
als   er   seine   Ordnung:   Tubercula  schuf,  fur   die  dahin   ge- 
horigen  Finnenausschlage  einer  neuen  Gattungsbezeichnung 
u.   verfiel  merkwurdigerweise  auf  den  bis  dahin  wenig  ge- 
brauchlichen    Terminus:    Akne,    anstatt    sich    der   bei   den 
Lateinern  iiblichen  Benennung:    Vari  oder  des  griechiscben 
Synonyms:    lonthos   zu   bedienen.     Das    griechische     Wort: 
Akne  hatte  der  byzantinische,   im  6ten  Jahrhundert  lebende 
Schriftsteller  Aetius,  dem  Willan  bekanntlich  auch  das  Wort: 
Ekzem  entnahm,  als  gleichbedeutend  mit  lonthos  gebraucht. 
Sauvages    (1706-1767),  der   in   seiner  beruhmten:   Nosologia 
methodica    (1760)     unter   Nachahmung  von    Linnes,   seines 
Zeitgenossen  u.  Correspondenten,  "Klassifikation  der  Pflanzen" 

i  Diese  Veranderung  von  Rosea  in  Rosacea  hat  schon  Ambroise  Par 6: 
"  Einem  an  Gutta  rosacea  leidenden  Kranken  muss  die  Vena  basilica,  alsdann 
die  Stirnvene  u.  die  Nasenvene  geoffnet  werden  und  ebenso  muss  man 
Blutegel  an  verschiedene  Teile  des  Gesichtes  applicieren.  Ebenso  setzt 
man  blutige  SchrSpfkopfe  an  die  Schultern."  Ebenso  Fernel  (1679): 
"Hae  pustulae  si  intensum  ruborem  habent,  Gutta  Rosacea  vocantur,  si 
durae  et  exiquo  et  frigido  et  crasso  humore  ac  velut  in  callum  concretae, 
Vari  nominantur. " 


8o  SIXTH   INTERNATIONAL 

die  Krankheiten  in  ein  naturhistorisches  System  zu  bringen 
suchte  u.  offenbar  auf  Plenck  u.  Willan  von  grosstem  Einflusse 
bei  ihrer  Bearbeitung  der  Hautkrankheiten  gewesen  ist, 
nahm  dieses  Wort:  Akne  als  Erster  aus  dem  Aetius  auf,  verband 
es  mit  deih  Namen:  Psydracia  fur  Eiterpusteln  u.  nannte  die 
Finnen:  Psydracia  Akne.  Willan,  hiervon  ausgehend,  machte 
nun  den  Namen  Akne  zum  Gattungsnamen  u.  gab  dieser 
Gattung  folgende  Definition:  "Tuberkulose  Geschwiilste, 
die  langsam  eitern  u.  hauptsachlich  dem  Gesichte  eigen 
sind. "  Von  irgend  einer  Beziehung  dieser  "Tuberkeln" 
auf  die  Talgdrusen  ist,  wie  man  sieht,  hier  noch  keine  Rede, 
u.  grade  weil  spater,  hauptsachlich  in  Frankreich,  der 
Begriff  Akne  eine  so  ungemein  grosse  Ausdehnung  erhielt  u. 
schliesslich  nicht  bloss  alle  Entziindungen  der  Talgdrusen, 
sondern  sogar  viele  Funktionsanomalien  derselben  umfasste, 
so  muss  man  sich  der  ursprunglichen  Bedeutung  dieses  Wortes 
wohl  bewusst  bleiben.  Willan  u.  Bateman  dachten  bei  ihrer 
Gattung  Akne  so  wenig  an  eigentliche  Talgdriisenaffektionen, 
dass  sie  selbst  bei  Beschreibung  der  zweiten  Art :  Acne  punctata 
(unserer  heutigen:  "entziindeten  Mitesser")  nur  beilaufig 
erwahnen,  dass  zuweilen  in  Folge  der  Ausdehnung  der 
Gange  durch  talgartige  Materie  die  "Drusen  selbst  sich 
entzunden"  u.  schwarzpunktierte  Tuberkel  bilden  neben  eben- 
solchen  Tuberkeln,  auf  welchen  keine  Punkte  zu  sehen  sind. 

Diese  von  der  heutigen  Anschauung  iiber  Akne  so  gnind- 
lich  abweichende  Ansicht  von  Willan  u.  Bateman,  den  Schopfern 
der  neuen  Nomenklatur,  wird,  wenn  noch  irgend  ein  Zweifel 
dariiber  existieren  sollte,  durch  eine  Anmerkung  ihres  Ueber- 
setzers  Blasius 1  illustriert,  welcher  bei  Gelegenheit  der  schwar- 
zen  Punkte,  welche  auf  manchen  Tuberkeln  bei  der  Akne 
vorkommen,  sagt:  "Es  sind  dies  die  Komedones,  Mitesser  oder 
Zehrwurmer,  die  eigentlich  garnicht  zur  Akne  gehoren  u. 
nur  insofern  bei  derselben  in  Betracht  kommen  als  sie  sich 
mit  ihr  complizieren  u.  sie  veranlassen  konnen.  Die  Auf- 
stellung  der  Acne  punctata  als  einer  besonderen  Art  lasst  sich 
deshalb  auch  nicht  rechtfertigen  und  man  konnte  hochstens 
daraus  eine  Varietat  der  Acne  simplex  machen. " 

Versetzt  man  sich  in  die  Anschauungen  Willans  zuriick, 

>  Bateman,  nach  der  7ten  Auflage  iibersetzt,  1835,  PS-  33°- 


DERMATOLOGICAL  CONGRESS  81 

so  wird  man  es  allerdings  gerechtfertigt  finden  mussen,  dass  er 
die  Gutta  rosacea  Plencks  als  4te  Art  unter  dem  Namen  Acne 
rosacea  in  seine  neue  Gattung  Akne  versetzte,  denn  auch  bei 
ihr  kommen  "entziindete  Tuberkel"  im  Sinne  seiner  Definition 
der  Akne  vor.  Willan  konnte  diese  Versetzung  ohne  Skrupel 
vornehmen,  denn  er  dachte  nicht  daran,  die  Acne  rosacea  damit 
zu  einer  Talgdnisenerkrankung  stempeln  zu  wollen.  War 
aber  fortan  die  Rosacea  an  die  Gattung  Akne  gebunden,  so 
war  es  auch  natiirlich,  dass  sie  die  sehr  bald  in  Frankreich  durch 
Rayer  u.  Biett  erfolgende  sprungweise  Entwicklung  des  Aknebe- 
griffes  mitmachen  musste  u.  so  nolens  volens  zu  einer  Talgdriis- 
enaffektion  wurde,  d.  h.  in  eine  ganz  schiefe  Stellung  geriet. 
Doch  verweilen  wir  zunachst  ein  wenig  bei  Willans  und 
Batemans  Zeitgenossen.  Der  bedeutendste  gleichzeitig  mit 
Willan  in  Frankreich  lebende  Dermatologe  war  Alibert  (1766- 
1837).  Er  war  bei  der  Schopfung  seines  ersten  grossen 
Werkes:  "Description  des  maladies  de  la  peau,  observe'es  a 
1'hopital  St.  Louis"  (1806-1827)  noch  ganz  unbeinflusst  von 
Willan.  Demgemass  ist  die  Rosacea  bei  ihm  bei  den  "Dar- 
tres" und  zwar  den  "Dartres  pustuleuses"  zu  finden  unter 
dem  deskriptiv  ganz  passenden  Namen:  "Dartre  pustuleuse 
Couperose  (Herpes  pustulosus  gutta-rosea) . "  Die  beige- 
gebene  Abbildung  (Tafel  21)  zeigt  einen  weiblichen  Kopf  mit 
einer  starken  Rote  in  Schmetterlingsform  auf  Nase  und 
Wangen  und  nur  sehr  wenigen  Papeln  und  Pusteln.1  In  der 
Beschreibung  wird  auf  die  diffuse  Rotung  (Couperose)  das 
meiste  Gewicht  gelegt.  Diese  Form  des  "pustulosen  Herpes" 
folgt  im  Werke  von  Alibert  auf  eine  andere:  "Dartre  pustu- 
leuse mentagre, ''  aus  deren  Abbildung  wir  unschwer  die 
Diagnose  Sykosis  oder  besser  die  eines  schuppigen  Ekzema 
barbae  mit  Eiterpusteln  an  den  Haarfollikeln  machen  konnen. 
Die  Bezeichnung  als  Dartre  und  Herpes  sowie  die  Verwand- 
schaft  mit  dem  Ekzem  des  Bartes,  alles  beweist,  dass  der  noch 
von  Willan  unbeeinflusste  Alibert  die  Couperose  des  Volkes 
wissenschaftlich  zu  einer  "Flechte, "  einer  ekzemartigen  Krank- 
heit  machen  wollte.  Zwischen  dieser  ersten  Auflage  von 

»  Die  entsprechende  Tafel  bei  Bateman  (Tafel  64)  zeigt  einen  mannlichen 
Kopf  mit  geringerer  Rote  in  Schmetterlingsform,  mehr  Angiektasien 
und  viel  zahlreicheren  "Tuberkeln,"  das  ist  Papeln  und  Pusteln. 

VOL.    I. — 6 


82  SIXTH  INTERNATIONAL 

Aliberts  Hauptwerk  und  der  zweiten,  welche  1835  unter  dem 
Titel:  "  Monographic  des  Dermatoses  "  erschien,  liegt  ein  un- 
scheinbares,  aber  fur  die  Dermatologie  folgenschweres  Ereignis, 
die  Reise  von  Biett  nach  England.  Biett  (1781-1840),  15 
Jahre  jiinger  als  Alibert,  mit  diesem  befreundet  und  von 
demselben  wesentlich  gefordert  und  an  das  Hospital  St. 
Louis  gezogen,  lernte  in  England  das  System  von  Willan  und 
Bateman  kennen  und  suchte  dasselbe  nach  seiner  Riickkehr 
durch  Schrift  (Dictionnaire  de  Medicine)  und  Vortrage  ein- 
zuburgern.  Obwohl  Alibert  im  grossen  und  ganzen  auf  sei- 
nem  rein  klinischen  Standpunkt  beharrte  und  es  zwischen 
ihm  und  seinem  einstigen  Schiller  zu  einer  Rivalitat  kam, 
welche  die  damalige  franzosische  Dermatologie  in  zwei 
Schulen,  die  Willan- Bateman' sche  und  die  Alibert' sche  teilte, 
hat  die  Richtung  von  Willan  mit  ihrer  Betonung  der  Wich- 
tigkeit  der  Effloreszenzen  und  mit  ihrer  einseitigen,  aber 
praktischen  Klassifikation  nach  diesen  ausseren  Merkmalen 
doch  zweifellos  Einfluss  auf  die  weitere  Ausgestaltung  des 
Alibert' schen  Systems  geubt.  Im  Jahre  1828  erschien  das 
Lehrbuch  von  Bietts  Schulern :  Cazenave  und  Schedel,  welches 
als  erstes  Lehrbuch  der  Willan' schen  Schule  in  Frankreich 
anzusehen  ist,  und  demgemass  finden  wir  in  der  7  Jahre 
spater  erschienenen  zweiten  Auflage  von  Alibert  ein  eigenes 
Genre  II:  Varus  der  Dermatoses  dartreuses,  welches  der 
Willan' schen  Gattung  Akne  nachgebildet  ist  und  neben  dem 
Varus  Comedo,  Varus  disseminatus,  Varus  frontalis,  dem 
Hordeolum  und  dem  Varus  mentagra  auch  den  Varus  gutta- 
rosea  enthalt.  So  gelangte  die  Couperose  auch  in  Frankreich 
wissenschaftlich  definitiv  unter  die  Finnenkrankheiten,  aller- 
dings  nicht  unbestritten. 

Schon  Rayer  (1793- 1867) 1  sagt:  "Da  man  in  Frankreich 
mit  dem  Namen  Couperose  eine  chronische,  pustulose  Entztind- 
ung  der  Talgdriisen  der  Gesichtshaut  zu  bezeichnen  pflegt,  so 
glaubte  ich  dem  Begriffe  Akne  eine  beschranktere  Bedeutung 
geben  zu  miissen.  .  .  .  Ich  habe  die  beiden  Formen  nur 
deshalb  getrennt,  um  die  gewohnlich  Couperose  genannte,  sehr 
hartnackige  Krankheit  des  Gesichtes  von  der  oft  durchaus  nicht 
schlimmen,  mitunter  auch  auf  die  Haut  des  Rumpfes  be- 

1  Trait£  theorique  et  pratique  des  maladies  de  la  peau.     1826. 


DERMATOLOGICAL  CONGRESS  83 

schrankten,    in  der  Jugend   vorkommenden  Akne  zu  unter- 
scheiden. " 

Demgemass  hat  Rayer  hinter  einem  ausfuhrlichen  Kap- 
itel  Akne  ein  ebenso  sorgfaltig  gearbeitetes,  selbstandiges 
Kapitel  uber  Couperose. 

Ebensowenig  wie  Rayer  lasst  sich  Devergie1  (1798-1879) 
seine  selbstandige  Beobachtung  durch  die  neue,  von  Eng- 
land aus  eindringende  Lehre  beeinflussen. 2  Er  macht  noch 
entschiedener  gegen  die  Unterordnung  der  Couperose  unter 
die  Akneformen  Front  als  jener.  Wahrend  Rayer  haupt- 
sachlich  die  verschiedene  Prognose  und  Lokalisation  und 
das  verschiedene  Alter  der  Patienten  bei  beiden  Krankheiten 
hervorhob,  spricht  sich  Devergie  folgendermassen  aus: 

"  Die  Couperose  ist  eine  Krankheit  der  Blutkapillaren  der 
Haut.  Wenn  die  Talgdriisen  hin  und  wieder  affiziert  werden, 
so  ist  es  nur  zufallig;  deshalb  trenne  ich  die  Couperose  von 
der  Akne,  welche  die  Mehrzahl  der  Autoren  mit  dieser  Krank- 
heit zusammengeworfen  hat.  Beobachtet  man  aber  die  Cou- 
perose in  ihrem  Beginne,  beobachtet  man  ihr  Fortschreiten, 
ihre  Entwicklung,  ihren  Ausgang,  so  wird  man  uns  zugeben, 
dass  unsere  Trennung  gerechtfertigt  ist. " 

Devergie  unterscheidet  nun  drei  Grade  der  Affektion,  die 
Couperose  als  einfaches  Erythem  ohne  Verdickung  der  Haut, 
diejenige  mit  Verdickung  der  Haut  und  die  tuberose  Form 
und  fugt  hinzu: 

"Nur  in  der  Form  mit  allgemeiner  Verdickung  der  Haut 
sieht  man  accidentelle  Aknepusteln  aufschiessen  unter  der 
Form  von  mehr  oder  weniger  grossen  Knoten,  die  zur  Vereit- 
erung  kommen;  aber  dieser  Zustand  ist  nur  voriibergehend 
und  vollstandig  accidentell. " 

Diesen  selbststandigen  Geistern  gegeniiber  steht  aber 
eine  weit  grossere  Menge  unselbstandiger  Autoren  in  Eng- 
land, Frankreich  und  Deutschland,  bei  welchen  nach  dem 
Vorgange  von  Willan  und  Biett  die  Rosacea  kurzweg  als 
Varietat  der  Akne  erscheint,  meistens  auch  unter  dem  Namen : 

1  Trait6  pratique  des  maladies  de  la  peau.     1 854. 

1  Es  ist  interessant,  dass  vor  den  franzttsischen  Dermatologen  der  ersten 
Halfte  des  vorigen  Jahrhunderts  es  auch  Rayer  und  Devergie  hauptsachlich 
sind,  welche  in  der  Ekzemfrage  Willan  gegenuber  ihre  Selbstandigkeit 
wahrten. 


84  SIXTH  INTERNATIONAL 

Acne  rosacea,  so  bei  Green  (1838),  dem  jungen  Erasmus 
Wilson  (1846),  Neligan  (1852),  Nayler  (1866)  in  England, 
bei  Gibert  (1840),  Duchesne-Duparc  (iSsg),1  Bazin  (1868) 
in  Frankreich,  Fuchs  (1840),  Riecke  (1841),  Kleinhans  (1866) 
in  Deutschland.  Interessant  ist  es  aber,  dass  der  einzig 
bedeutende  Englander  tinter  denselben :  Erasmus  Wilson  sich 
bei  gereifter  Erfahrung  in  einem  spateren  Werke  von 
der  Willan-Biett'schen  Lehre  frei  machte.  In  seinen  187 1 
erschienenen  "Lectures"  benennt  Wilson  die  Affektion 
wieder  mit  dem  alien  Namen:  Gutta  rosea  und  sagt: 
"Gutta  rosea  has  heretofore  been  confounded  with  acne 
under  the  name  of  acne  rosacea"  (p.  135).  Bazin  hingegen 
machte  einen  Weg  in  umgekehrter  Richtung.  In  der  ersten 
Auflage  seiner:  "  Legons  the'oriques  et  cliniques  sur  les  affec- 
tions cutanees  de  nature  arthritique  et  dartreuse  (1860,  von 
Sergent  redigiert)  sagt  er:  "  Die  Couperose  ist  eine  erythema- 
tose  Affektion,  characterisiert  durch  die  Erweiterung  der 
Gefasskapillaren  der  Haut.  Die  meisten  Autoren  haben 
sie  mit  Unrecht  mit  der  Acne  rosacea  zusammengeworfen ; 
denn  wenn  Aknepusteln  sich  auf  den  Flecken  der  Couperose 
entwickeln,  so  geschieht  es  nur  zufallig  und  als  Complication; 
ich  werde  daher  die  Couperose  getrennt  von  der  Acne  rosacea 
beschreiben. "  In  der  zweiten  Auflage  desselben  Werkes 
( 1868,  von Besnier redigiert)  heisst  es :  "In  meinen Vorlesungen 
von  1860  habe  ich  beide  Affektionen  getrennt.  Aber  seitdem 
habe  ich  erkannt,  dass  bei  der  Couperose,  die  wesentlich 
durch  die  Entwicklung  einer  erythematosen  Rote  von  grosserer 
oder  geringerer  Intensitat  characterisiert  wird,  immer  und 
selbst  von  Anfang  an  eine  Anschwellung  der  Talgdriisen, 
rudimentarer  Pusteln,  besteht. "  Demgemass  behandelt  er 
wieder  beide  Affektionen  in  einem  Kapitel  unter  dem  Titel: 
"Acne  rosee  ou  Couperose  arthritique." 

Wir  kommen  nun  zu  dem  wichtigsten  Werke  der  2ten 
Halfte  des  vorigen  Jahrhunderts,  zum  Lehrbuche  Ferdinand 
Hebras  (1860).  Wie  dasselbe  epochemachend  und  fur  lange 
Zeit  massgebend  auf  alle  Teile  der  Dermatologie  gewirkt 
hat,  so  entschied  es  auch  die  Rosaceafrage  auf  mehrere  Jahr- 
zehnte  hinaus.  Wenn  noch  heute  die  meisten  Lehrbiicher 

1  Unter  dem  Namen :  Varus  e'rythe'mateux-pustuleux. 


DERMATOLOGICAL  CONGRESS  85 

ein  Kapitel  Acne  Rosacea  fiihren,  so  ist  dieser  Anachronismus 

wohl  sicher  die  Folge  der  treuen  Anlehnung  fast  aller  spateren 

dermatologischen    Werke    an    Hebras    Lehrbuch.      Um    so 

wichtiger  ist  es,  die  Begriindung  kennen  zu  lernen,  welche 

F.   Hebra  fur  seine  Entscheidung  in  der  Rosaceafrage  gibt. 

Er  sagt:    "Aus  den  angefuhrten    geschichtlichen   Daten  ist 

ersichtlich,   dass  viele  unserer  Vorfahren  und  Zeitgenossen 

die  Acne  rosacea  als  eine  Species  der  uberhaupt   Akne   ge- 

nannten  Krankheit  auffassen  und  auch  das  Wesen  der  Couperose 

nur  in   einer   Entzundung  der   Talgdriisen  suchen.      Schon 

im  Jahre    1846    habe   ich   bei  Veroffentlichung  meiner  Ein- 

teilung  der  Hautkrankheiten  mich  dahin  ausgesprochen,  dass 

die  Acne  rosacea  nicht  in  einem  exsudativen  Prozesse,  sondern 

in     einer    Gefass-  und  Zellgewebsneubildung    bestehe,   dass 

dieselbe  jedoch  auch  haufig  mit  Acne  disseminata  combiniert 

sei,  und  aus  diesem  Grande  ihre  Besprechung  eigentlich  in 

dem  Kapitel  tiber  Neubildung  stattfinden  sollte.      Wenn  ich 

aber   auch   gegenwartig  es   fur  zweckmassiger  erachte,   der 

Acne  rosacea  an  diesem  Platze  und  zwar  in  Gesellschaft  mit 

den    anderen    Akne    genannten     Krankheiten    gebiihrende 

Betrachtung  zu  widmen,  so  ist  hierzu  nicht  etwa  eine  einge- 

tretene    Aenderung    meiner    fruheren    Ansichten    uber    das 

Wesen  dieser  Krankheit  Veranlassung  gewesen,  sondern  mein 

Bestreben,  in  meinem  System,  nach  Art  der  Naturhistoriker 

die  Hautkrankheiten  in  Gruppen  zusammenzustellen,  wobei  ich 

auf  die  Aehnlichkeit  oder  Gleichartigkeit  aller  Erscheinungen 

Riicksicht  nehme,  nicht  aber  bloss  Ein  Kriterium  als  Ein- 

teilungsgrund  gelten  zu  lassen  fur  zweckmassig  halte.     Ich 

bin  demnach  immer  nock  der  festen   Ueberzeugung,  dass  bei 

Acne  rosacea  die  allenfalls  vorhandene  Entziindung  der  Schmeer- 

drusen  und  der  Hautgebilde  selbst  nur  eine  zufdllige,  allerdings 

haufig  vorkommende  Complication  der  Krankheit  ausmache, 

ohne  dass  dieselbe  zur  Characteristik  der  Krankheit  erforder- 

lich  ware.      Den  Beweis  fur  die  Richtigkeit  und  Berechti- 

gung   dieser   Auffassung   liefert   die  tagliche  Erfahrung,   zu 

deren   Wurdigung   wir   auf    die   folgende    Beschreibung  der 

Symptome  und  des  Verlaufes  der  Acne  rosacea  verweisen." 

Wir    entnehem    diesen    einleitenden    Worten    zunachst    mit 

Befriedigung,   dass   auch  F.    Hebra,   wie    alle    selbstandigen 


86  SIXTH  INTERNATIONAL 

Beobachter  vor  ihm,  zwischen  den  Formen  der  Akne  und 
denen  der  Rosacea  nur  eine  dussere  Aehnlichkeit  wahrnahm, 
beide  Erkrankungen  aber  fur  wesentlich  verschieden  ansah. 
Um  so  mehr  uberrascht  deshalb  die  Logik  der  Schlussfol- 
gerung,  dass  trotzdem  die  Rosacea  bei  den  Akneformen 
abzuhandeln,  mithin  auch  der  Terminus:  Acne  rosacea  bei- 
zubehalten  sei.  F.  Hebra  sagt  mit  Recht,  eine  Gruppenbildung 
musse  nicht  nur  auf  Ein  Kriterium,  sondern  auf  die  Aehn- 
lichkeit oder  Gleichartigkeit  aller  Erscheinungen  hin  gegriindet 
werden,  und  nun  stellt  er  doch,  grade  nur  wegen  eines  einzigen 
Symptoms,  der  Talgdrusenerkrankung,  die  Rosacea  zur  Akne, 
wahrend  alle  iibrigen  Symptome  beider  Erkrankungen  ver- 
schieden sind;  er  tut  also  grade  das  bei  der  Rosacea,  was 
er  bei  seinem  ganzen  System  zu  vermeiden  wiinscht.  Hebra 
betont  namlich  nicht  nur — wie  Rayer  und  Devergie  vor  ihm 
— die  der  Rosacea  allein  zukommenden  Symptome  der  Kap- 
illarerweiterung  und  eigentumlichen  Schlangelung  der  gross- 
eren  Blutgefasse,  die  roten  Protuberanzen  ohne  eitrigen 
Inhalt,  die  bei  maximaler  Entwicklung  zu  den  Verunstaltungen 
des  Rhinophyms  fuhren,  die  Beschrankung  auf  das  Gesicht, 
die  subjektiven  Empfindungen,  die  Variabilitat  der  Bilder 
im  Anfange  und  im  Verlaufe  der  Krankheit,  er  stellte  sogar 
schon  15  Jahre  fruher  in  einem  eigenen  Artikel  die  Behauptung 
auf,  dass  die  Rosacea  gar  nicht  zu  den  exsudativen,  sondern 
zu  den  proliferativen  Prozessen  gehore,  eine  in  dieser  ex- 
tremen  Weise  sogar  neue  Anschauung,  deren  konsequenz 
ebenfalls  nur  in  einer  vollkommenen  Trennung  der  Rosacea 
von  der  Acne  bestehen  kann.  Trotz  aller  dieser  Verschieden- 
heiten  soil  nun  wiederum  die  Rosacea  eine  Abart  der  Acne 
sein,  auf  das  einzige  Symptom  der  Talgdrusenerkrankung 
hin,  und  von  diesem  Symptom  sagt  dabei  Hebra  ausdrucklich, 
dass  es  fehlen  konne,  dass  es  eine  zufdllige  Komplikation  sei. 
Kurz,  Hebra  verwirft  auf  der  einen  Seite  jede  Gruppierung 
und  Zusammenstellung  von  Hautkrankheiten  bloss  auf  ein 
Symptom  hin  und  behauptet,  dass  dieses  Verfahren  nicht 
das  seinige  sei,  erweist  dann,  dass  Rosacea  und  Akne  zwei 
wesentlich  verschiedene  Krankheiten  sind,  stellt  sie  nun  aber 
doch  in  eine  Gruppe  bloss  auf  ein  Symptom  hin  und  behauptet 
gleichzeitig  noch,  dass  dieses  eine  Symptom  bei  der  Rosacea 


DERMATOLOGICAL  CONGRESS  87 

auch  fehlen  konne,  sodass  in  diesem  letzteren  Falle  nach  seiner 
eigenen  Anschauung  Rosacea  und  Akne  zusammengestellt 
waren,  ohne  ein  einziges  Symptom  gemeinsam  zu  haben.  Ver- 
steht  ein  lebender  Fachgenosse  die  Logik  dieses  Verfahrens? 

In  diesem  Falle  hat  einmal  die  Autoritat  des  Autors  die 
Zeitgenossen  fur  den  handgreiflichen  Mangel  an  Logik  blind 
gemacht;  die  gelungene,  ja  drastische,  mit  Hebra'scher  Vir- 
tuositat  gegebene  klinische  Schilderung  Hess  die  fehlerhafte 
Einrahmung  des  Bildes  vollig  vergessen.  Leider  hat  aber 
dieser  iiberflussige  Anachronismus,  von  Hebra  in  unverstand- 
licher  Weise  sanktioniert,  auf  lange  Zeit  in  der  Literatur 
Burgerrecht  gewonnen.  Zunachst  waren  es  die  Schiiler 
Hebras,  welche  in  ihren  Compendien  die  so  gefasste  Lehre 
von  der  "Acne  rosacea"  aufnahmen:  /.  Neumann  (1869), 
Kaposi  (1879),  Hebra  jr.  (1884),  dann  wurde  dieselbe  gewiss- 
enhaft  in  die  iibrigen  deutschen  Lehrbucher  von  Behrend 
(1879),  Veiel  (1884),  Lesser  (1885),  Joseph  (1892),  Wolff 
(1893)  Kopp  (1893),  Thimm  (1901)  Neisser  und  Jadassohn 
(1901),  Jessner  (1902),  Kromayer  (1902)  ubernommen. 

Allerdings  variiert  die  Begrundung  dieser  Unterbringung 
der  Rosacea  bei  der  Akne  etwas.  Neisser  und  Jadassohn1 
widmen  der  "Rosacea,"  einem  Leiden  mit  vielgestaltiger 
Aetiologie  ein  eigenes  Kapitel,  fuhren  dann  aber  die  "Acne 
rosacea"  im  Aknekapitel  (pg.  162)  besonders  auf  als  eine 
Complication  der  Rosacea  mit  der  Acne  vulgaris.  Jessner2 
erwahnt  verschiedene  Moglichkeiten :  die  Rosacea  besteht 
fur  sich,  oder  es  tritt  sekundar  Akne  hinzu,  oder  zu  einer 
Akne  gesellt  sich  die  Rosacea.  Dieser  "  Complicationstheorie," 
welche  die  vorhandenen  Schwierigkeiten  allerdings  theoretisch 
auf  eine  einfache  Weise  zu  beseitigen  scheint,  huldigen  mehr 
oder  weniger  ausgesprochen  die  meisten  Autoren.  Hin  und 
wieder  leuchtet  ein  Schimmer  besserer  Erkenntniss  auf,  aber 
gleich  versinkt  er  wieder  in  dem  Grau  des  Dogmas.  So  sagt 
Joseph3:  "Streng  genommen  mussten  wir  allerdings  diese 
Affektion  nicht  unter  den  einfachen  entzundlichen  Haut- 
krankheiten  anfiihren,  sondern  sie  den  Zirculationsstorun- 

>  Krankheiten  der  Haut  in  Ebsteins  Handbuch  der  prakt.  Medizin. 

'  Dermatologische  Vortrage.     Heft  a.     Acne.  1902. 

»  Lehrbuch  der  Haut-  und  Geschlechtskrankheiten.     II  Aufl.  1895. 


88  SIXTH  INTERNATIONAL 

gen,  resp.  in  spateren  Stadien  den  progressiven  Ernahrungs- 
storungen  der  Haut  einreihen.  Indessen  ziehen  wir  es 
vor,  dem  Vorgange  Hebras  folgend,  aus  Zweckmdssigkeits- 
grunden  schon  hier  die  Acne  rosacea  zu  besprechen,  da  sie 
sick  klinisch  schwer  von  der  Acne  simplex  trennen  Idsst.  "  Eine 
bessere  Begriindung  als  bei  F.  Hebra  kann  ich  allerdings 
hierin  nicht  erkennen. 

Ganz  ohne  Widerspruch  blieb  diese  Auffassung  allerdings 
innerhalb  der  Wiener  Schule  auch  nicht.  Auspitz l  stellt 
die  Acne  rosacea  zu  seinen  "  angioneurotischen  Dermatosen  " 
unter  dem  Namen:  Erythema  angiectaticum  und  erklart  sie 
fur  eine  vasomotorische  Stoning  mit  Gefassdilatation  und 
Gefassneubildung.  Jarisch2  sagt:  "Von  alien  Erkrankungen, 
welche  den  Namen  der  "Akne"  fuhren,  gebuhrt  derselbe  am 
wenigsten  der  in  Rede  stehenden  Form,  nachdem  die  bei 
derselben  zu  beobachtenden  Follikelentziindungen  nur  die 
Bedeutung  sekundarer  Vorgange  haben,  welche  lange  Zeit 
hindurch  vollkommen  fehlen  konnen.  Die  Grundlage  des 
Leidens  bilden  hyperamische  Vorgange"  etc.  Trotzdem 
handelt  es  sich  auch  bei  Jarisch,  wenn  auch  nur  sekundar, 
um  Hinzutreten  von  "  Akneknoten. "  Lang3  endlich  zieht 
von  alien  Schulern  Hebras  als  Erster  die  Konsequenz  der 
Hebra' schen  Lehre  und  behandelt  die  Acne  rosacea  unter 
dem  Hauptnamen  Rosacea  bei  den  Neubildungen.  Er  sagt: 
"Durch  die  irrige  klinische  Vorstellung,  die  man  von  der 
Kupferrose  hatte,  kam  sie  nicht  nur  zur  Bezeichnung  Akne, 
sondern  wurde  auch  meist  der  Acne  vulgaris  angereiht; 
doch  handelt  es  sich  um  eine  Neubildung,  die  sich  in  den 
leichtesten  Fallen  bloss  auf  Erweiterung  und  geringe  Ver- 
mehrung  der  Gefasse  bezieht,  wahrend  in  den  fortgeschrit- 
tensten  und  hochgradigen  Fallen  das  Bindgewebe  und  die 
Talgdriisen  neben  den  Gefassen  in  erheblichem  Masse  an 
der  Neubildung  teilhaben. "  Konsequenterweise  bezeichnet 
Lang  die  bei  der  Rosacea  auftretenden  Knotchen  und  Knoten 
auch  nicht  mehr  als  Akneknoten,  indem  er  auch  hier  mit  der 
alten  Willan'schen  Anschauung  definitiv  bricht. 

1  System  der  Hautkrankheiten.     1881. 

2  Die  Hautkrankheiten.     1900.     S.  445. 

3  Lehrbuch  der  Hautkrankheiten  1902,  pg.  586. 


DERMATOLOGICAL  CONGRESS  89 

Was  Lang  in  letzter  Zeit  fur  die  Rosacea  innerhalb  der 
Wiener  Schule  leistete,  tat  Hardy1  etwas  fruher  innerhalb 
der  franzosischen.  Unter  dem  Namen  Acne  congestive  ou 
Couperose  trennt  er  die  Rosacea  vollstandig  von  den  Ak- 
neformen  ab  und  bespricht  sie  im  Kapitel  der  "Congestions 
cutanees. "  Er  sagt:  "Die  congestive  Akne,  die  sich  auf 
eine  Stoning  der  kapillaren  Zirculation  der  Gesichtshaut 
bezieht,  muss  sorgfaltig  von  den  anderen  Aknearten  geschie- 
den  werden,  von  denen  sie  sich  wesentlich  durch  den  anatom- 
ischen  Sitz  unterscheidet ;  auf  sie  muss  der  Name  Couperose 
beschrankt  bleiben,  der  mit  Unrecht  als  Synonym  von  Acne 
gebraucht  worden  ist. "  Bald  darauf  erfahren  wir  auch  aus 
einer  Anmerkung  von  Besnier  und  Doyon,2  was  denn  eigentlich 
im  heutigen  Frankreich  der  Sinn  des  specifisch  franzosischen 
Ausdrucks  "Couperose"  ist,  der  sich  neben  dem  der  Acne 
rosacea  daselbst  seit  100  Jahren  erhalten  hat:  "  In  Frankreich 
will  der  Ausdruck:  Couperose  einfach  sagen:  permanente 
Congestion  des  Gesichtes,  mit  oder  ohne  Follikulitiden,  mit 
oder  ohne  Varikositaten.  Man  sagt:  Diese  Person  ist 
couperose' e,  teint  couperose,  etc.  Im  allgemeinen  wird  dem 
Wort  Couperose  von  den  Laien  eine  ominose  Bedeutung 
zugelegt;  dieselbe  Patientin,  die  trostlos  sein  wiirde,  wenn 
ihr  Arzt  zugibt,  dass  sie  an  Couperose  leidet,  ist  voll  Zuver- 
sicht,  wenn  er  ihr  erklart,  sie  leide  bloss  an  einer  congestiven 
oder  erythematosen  Akne.  Medizinisch  ist  der  Ausdruck  an- 
genommen  und  annehmbar;  indessen  ist  er  doch  wenig  ge- 
brauchlich,  und  es  erscheint  uns  unntitz,  ihm  eine  prazisere 
und  solidere  Deutung  zu  geben  als  ihm  tatsachlich  zu- 
gestanden  wird. " 

Aus  dieser  Bemerkung  konnen  wir  mancherlei  entnehmen. 
Zunachst,  dass  das  Wort  Couperose  in  Laienkreisen  einen 
weniger  gutartigen  Sinn  hat  als  Akne,  was  wohl  damit  zusam- 
menhangt,  dass  schon  der  Laie  merkt:  die  Comedonenakne 
vergeht  mit  der  Zeit,  die  rote  Nase  bleibt  mir  oder  wird  schlim- 
mer  mit  der  Zeit.  Sodann,  dass  die  franzosischen  Aerzte, 
welche  von  den  konstitutionellen  Wesen  der  Rosacea  iiber- 

1  Trait6  des  maladies  de  la  peau,  1886,  pg.  530. 

2  Notes  et  additions  zur  franzosischen  Uebersetzung  des  Lehrbuches  von 
Kaposi,  2te  Aufl.  1891,  pg.  750. 


90  SIXTH  INTERNATIONAL 

zeugt  sind,  es  nicht  vermocht  haben,  durch  eine  einfache 
Heilung  das  Publicum  von  der  Benignitat  der  Rosacea 
allmahlich  zu  iiberzeugen.  Endlich  geht  fiir  uns  noch  daraus 
hervor,  dass  das  Wort:  Couperose  in  Frankreich  kaum 
eine  wissenschaftliche  Verwertung  finden  wird  und  der  Ter- 
minus Rosacea  auch  dort  fiir  eine  von  der  Akne  unabhangige 
Krankheit  frei  ist. 

Auch  Leloir  und  Vidal  ( 1889)  trennen  wohl  noch  die  Ros- 
acea unter  dem  Namen  Couperose  von  der  Akne,  reihen  sie 
derselben  aber  doch  direkt  an,  "da  die  Aknepustel  eines  der 
wesentlichen  Elemente  der  Kupferrose  in  ihrem  entwickelten 
Stadium"  und  diese  "eigentlich  nichts  als  eine  auf  chronisch 
congestionischer  Haut  entwickelte  Akne"  ist.  So  ist  es  denn 
nicht  wunderbar,  dass  auch  in  die  neueren  franzosischen 
Lehrbiicher  die  Theorie  von  der  "zufalligen  Complikation 
der  zwei  eigentlich  nicht  zusammengehorenden  Affektionen 
Akne  und  Rosacea"  Eingang  gefunden  hat. 

Tenneson  (1893),  obwohl  er  fiir  Rosacea  eine  andere 
Behandlung,  namlich  eine  Ekzembehandlung  (mit  Caoutchouc 
und  Maske)  empfiehlt,  halt  die  Acne  rosacea  doch  fiir  eine 
"Association  zweier  distinkter  Affektionen." 

Brocq  (1892)  in  seinem  "  Traitement  des  maladies  de  la 
peau"  bedient  sich  des  Ausdrucks:  Acne  rosacee,  motiviert 
aber  diese  Wortzusammenstellung  in  einer  ganz  neuen  Weise, 
namlich  durch  iherapeutische  Rucksickten.  Er  sagt :  ' '  Die 
klinischen  Typen,  die  man  iibereingekommen  ist  unter  dem 
Namen  Couperose  zusammenzufassen,  sind  sehr  verschiedener 
Art.  Gewisse  derselben  scheinen  uns  durchaus  nicht  unter 
die  "Acnes"  in  eigentlichem  Sinne  eingereiht  werden  zu  kon- 
nen.  Wir  studieren  sie  hier  nur,  um  die  Darstellung  der  Be- 
handlung zu  erleichtern,  welche  bei  alien  ihren  Varietdten 
sozusagen  dieselbe  ist  wie  bei  den  Varietdten  der  wahren  Acne." 
In  Brocqs  neuem  Lehrbuch  "Traite  elementaire  de  Derma- 
tologie  pratique"  (1907)  kehrt  (Bd.  I,  pg.  830)  derselbe  Satz 
wieder,  wie  denn  auch  das  ganze  Kapitel  ziemlich  wortlich 
dasselbe  gibt  wie  dasjenige  des  alteren  Werkes  von  1892. 

Dubreuilh  hat  als  der  Erste  in  Frankreich  in  seinem  Leit- 
faden  ( 1899)  folgenden  Satz  aufgestellt,  obwohl  er  in  Bezug  auf 
die  Pathogenese  der  Rosacea  der  Complikationstheorie  huldigt : 


DERMATOLOGICAL  CONGRESS  91 

"Das  seborrhoische  Ekzem  des  Gesichtes  1st  zuweilen  sehr 
schwer  von  der  Acne  Rosacea  zu  unterscheiden ;  es  unter- 
scheidet  sich  durch  seine  Neigung,  Gruppen  oder  umschriebene 
Flecke  zu  bilden,  aber  nicht  selten  sieht  man  beide  Affektionen 
kombiniert  auf  einer  seborrhoischen  Haut,  unter  dem  Ein- 
flusse  seborrhoischer  Bedingungen.  Diese  intermedidren 
Formen  zwischen  Acne  rosacea  und  Ekzem  sind  besonders  von 
Brocq  studiert  worden. " 

Dieser  Satz  erweckt  ja  fast  die  Vorstellung,  als  wenn 
Dubreuilh  und  Brocq  hin  und  wieder  Uebergange  von  der 
Rosacea  zum  Ekzem  sehen  wurden.  Das  ist  aber  durchaus 
nicht  der  Fall.  Weder  bei  Dubreuilh  noch  bei  Brocq,  selbst  in 
dessen  neuestem  Lehrbuch,  spielt  das  seborrhoische  Ekzem  in 
der  Aetiologie  der  Rosacea  die  geringste  Rolle.  Nach  ihrer 
Auffassung  handelt  es  sich  in  solchen  Fallen  immer  nur  um 
eine  ' '  Complication. ' ' 

Auch  die  jungsten  franzosischen  Autoren  reproducieren 
immer  nur  wieder  mit  anderen  Worten  die  "  Complications- 
theorie,"  so  Hallopeau  in  Robins  "  Traite"  de  Therapeutique 
appliquee"  ( 1897),  Leredde  ("  Therapeutique  des  maladies  de  la 
peau,"  (1904),  endlich  Thibierge  in  dem  grossen  Sammelwerke : 
"La  pratique  dermatologique  "  (1900).  Letzterer  sagt  nach 
einem  kurzen  Expose  tiber  die  Vermischung  der  zwei  Grund- 
faktoren:  der  Gefasserweiterung  und  der  "Acn6  pustuleuse" 
bei  dieser  Erkrankung:  "Nach  unserer  Ansicht  ist  die  formelle 
und  absolute  Trennung  der  Couperose  von  der  Acne  rosacee 
vraie  zur  Zeit  unmoglich;  wenn  die  Couperose  auch  in  der 
Tat  sehr  lange  in  einem  rein  kongestiven  Stadium  bestehen 
kann,  geht  sie  doch  gewohnlich  spater  oder  fruher  in  eine 
Acne  rosacea  mit  Pusteln  iiber. "  Aus  diesem  einen  Satze 
geht  die  ganze  Schwierigkeit  der  Sachlage  fur  die  modernen 
franzosischen  Dermatologen  hervor;  ja,  die  Unmoglichkeit, 
in  Frankreich  zu  einer  einfachen  und  klaren  Begriffsbestim- 
mung  auf  dem  Gebiete  dieser  Hauterkrankung  zu  kommen. 
Gewiss  had  Thibierge  recht,  dass  es  unmoglich  ist,  die  Coupe- 
rose  von  der  "Acne  Rosacea  "  zu  trennen ;  darum  handelt  es  sich 
aber  ja  auch  gar  nicht.  Es  handelt  sich  vielmehr  darum,  die 
Couperose  (unsere  Rosacea)  von  der  "Akne"  zu  trennen,  und 
das  ist  ganz  leicht.  Wenn  die  franzosischen  Autoren  doch  nur 


92  SIXTH  INTERNATIONAL 

einsehen  wollten,  wie  grosse  Schwierigkeiten  sie  sich  kiinst- 
lich  grossgezogen  haben  durch  ihren  orthodoxen  und  besonders 
in  neuerer  Zeit  ubertriebenen  Willanismus,  der  dem  Worte 
Akne  eine  immer  grossere  Ausdehnung  gibt.  Anstatt  das 
Wort  Akne,  das  Willan  zu  einem  Gattungsnamen  fur  ver- 
schiedene  Zustande  machte,  seines  Gattungscharakters  zu 
entkleiden  und  in  moderner  Denkungsweise  einer  einheit- 
lichen  Krankheit,  einem  paihologischen  Individuum  anzuhangen, 
erweiterten  sie  den  Begriff  Akne  so  lange,  bis  er  zu  ihrem 
eigenen  Leidwesen  auch  die  Couperose  umfassen  konnte. 
Statt  die  Individuen  "Rosacea"  (Couperose)  und  "Acne" 
(juvenilis)  scharf  zu  trennen  und  dann  diese  Namen  angstlich 
bei  anderen  Affektionen  zu  meiden,  machten  sie  aus  der  Akne 
ganz  unnotigerweise  ein  Synonym  des  viel  ausdrucksvolleren 
Begriff s  "  Folliculitis.  "  Fanden  sie  nun  irgend  eine  "  Folli- 
culitis"  auch  bei  der  Rosacea,  so  sank  diese,  allem  natiirlichen 
pathologischen  Instinkt  zum  Trotz,  in  den  alleinseligmach- 
enden  Schoss  der  "Akne"  zuriick.  Uns  genieren  dagegen  die 
Follikulitiden  bei  der  Rosacea  nicht  im  mindesten,  denn  wir 
haben  den  Begriff  "Akne"  auf  die  Acne  juvenilis  mit  echten 
Comedonen  beschrankt,  und  da  wir  bei  den  Papel-Pusteln  der 
Rosacea  die  echten  Comedonen  vermissen,  so  ist  fur  uns  die 
Rosacea  pustulosa  auch  keine  "Complication  mit  Acne 
punctata,"  sondern  eine  Komplikation  mit  irgendwelcher 
Folliculitis,  deren  Natur  noch  naher  bakteriologisch  zu  bestim- 
men  ist  und  die  wahrscheinlich  nur  eine  Steigerung  dersel- 
ben  Entziindung  darstellt,  die  iiberhaupt  die  Rosacea 
charakterisiert. 

Ich  sagte,  die  jiingeren  franzosischen  Autoren  sind  ortho- 
doxe  Wtllanisten.  Das  waren  die  alteren  franzosischen 
Autoren  noch  nicht.  Rayer,  Devergie  und  Hardy  machten 
bemerkenswerte  Ansatze  dazu,  aus  dem  Netze  Willan' scher 
Gattungsbegriffe  heraus  zu  kommen.  Ihr  klinischer  Takt  wies 
sie  darauf  hin,  die  alte  franzosische  Couperose  von  der  neuen 
englischen  Akne  zu  unterscheiden.  Da  sie  aber  nicht  gleich- 
zeitig  den  Begriff  Akne  eng  genug  und  scharf  definierten, 
verstrickten  sich  ihre  Nachfolger  wieder  in  dem  Willan' schen 
Netze  der  alles  umfassenden  Akne. 

Eine  ganz  ahnliche  Entwicklung  nahm  die  Rosaceafrage 


DERMATOLOGICAL  CONGRESS  93 

in  Nordamerika.  Am  Anfange  stehen  die  beiden  Lehrbiicher 
von  Piffard:  "  An  Elementary  Treatise  upon  Diseases  of  the 
Skin"  (1876)  und  "A  Treatise  on  the  Materia  Medica  and 
Therapeutics  of  the  Skin  "  ( 188 1).  In  dem  ersteren  Lehrbuch 
nennt  Piffard  die  Affektion  kurzweg  Rosacea  und  sagt: 
"  Die  Affektion  wird  gewohnlich  mit  der  Akne  als  eine 
Varietat  der  letzteren  in  eine  Klasse  gebracht  und  haufig 
Acne  rosacea,  zuweilen  auch  Gutta  rosea  genannt.  Erstere 
Benennung  ist  unphilosophisch,  insofern  wir  Akne  als  eine 
Affektion  der  Talgdriisen  definiert  haben."  Im  zweiten  sagt 
er — wohl  der  erste  Autor,  der  sich  so  deutlich  ausdriickt — : 
"Die  abgerundeten  Erhebungen  oder  Knotchen  (Tubercles) 
sind  keine  Akneknotchen,  sondern  Verdickungen  der  ganzen 
Haut,  die  naturlich  viele  Talgdriisen  einschliessen."  Dem 
gegenuber  vertreten  wieder  Duhring  in  der  ersten  Auflage 
seines  Lehrbuches:  "A  Practical  Treatise  on  Diseases  of  the 
Skin"  (1877),  Bulkley  in  seiner  Monographic:  "Acne"  (1885), 
Ravogli  in  seinem  Buch  iiber  "  Die  Hygiene  der  Haut "  ( 1888), 
und  Hyde  und  Montgomery  in  ihrem  Lehrbuch  der  Hautkrank- 
heiten  ( 190 1)  die  Complicationstheorie  der  neueren  deutschen 
und  franzosischen  Autoren.  Keiner  von  ihnen  betont  diesen 
Standpunkt  so  energisch  wie  Bulkley:  "  Manche  Falle  dieses 
Ausschlags  weichen  so  erheblich  von  den  anderen  Akneformen 
ab,  dass  einige  Autoren  dazu  verleitet  wurden,  die  Acne  rosacea 
ganz  von  der  Gruppe  der  Talgdriisenerkrankungen  zu  trennen 
und  sie  bloss  als  Rosacea  zu  bezeichnen.  Wilson  reiht  sie 
sogar  unter  die  Ekzeme  ein  mit  der  Bezeichnung  Gutta  rosea. 
Aber  genauere  Beobachtung  der  Krankheit,  sowohl  in  klinischer 
wie  pathologischer  und  therapeutischer  Hinsicht  und  weiter 
die  haufige  Combination  mit  anderen  Akneformen  deuten  stark 
auf  ihren  Zusammenhang  mit  den  letzteren  hin  und  bestatigen 
die  Meinung  derer,  die  sie  seit  langem  als  eine  Form  der  Akne 
angesehen  haben."  Das  neueste  Lehrbuch  von  Stelwagon 
(1902),  dem  hervorragendsten  Schiller  Duhrings,  nimmt 
einen  objektiveren  Standpunkt  ein,  geht  aber  der  Entscheidung 
zwischen  den  Anschauungen  von  Piffard  und  Bulkley  aus  dem 
Wege.  Stelwagon  sagt:  "Die  Akne  oder  aknegleichen 
Lasionen  sind  meistens  denen  der  gewohnlichen  Akne  ahn- 
lich,  zu  welcher  Affektion  die  Acne  rosacea  sicher  Beziehungen 


94  SIXTH  INTERNATIONAL 

hat,  obgleich  dieses  neuerdings  von  anderen  Autoren  geleugnet 
wird,  welche  die  papulosen  und  pustulosen  Lasionen  fur  ganz 
verschieden  von  denen  der  Akne  erklaren."  Hierzu  ist  nur  zu 
bemerken,  dass  die  Trennung  der  Willan'schen  Acne  rosacea 
von  der  Akne  schon  sehr  alt  ist  und  die  Opposition  gegen  Wil- 
lans  Klassifizierung  unmittelbar,  in  Frankreich  schon  von  Rayer 
und  zwar  sachlich  und  formell,  in  Deutschland  von  Hebra 
allerdings  nur  sachlich  eingeleitet  wurde,  also  jedenfalls 
von  Dermatologen  ausging,  denen  man — entgegen  der  Ansicht 
von  Bulkley — grade  eminente  klinische  Beobachtungsgabe  zuge- 
stehen  muss.  Den  Irrtum  von  Stelwagon  hebe  ich  nur  hervor, 
weil  er  ein  allgemeiner  zu  sein  scheint.  Die  altere  Genera- 
tion der  Dermatologen  von  heute  ist  innerhalb  der  von  Frank- 
reich ausgehenden  Stromung  aufgewachsen,  die  den  Begriff 
Akne  als  Gattungsnamen  ungebuhrlich  erweiterte.  Hier- 
durch  wurden  die  nock  dlteren,  grade  auf  richtiger,  klinischer 
Einsicht  ruhenden  Anschauungen  iiber  Rosacea  zuriickge- 
drangt,  und  wenn  wir  heute  den  letzteren  wieder  und  dieses 
Mai  endgultig  zum  Siege  verhelfen  wollen,  so  gehen  wir  damit 
zunachst  nur  wieder  auf  den  alien  Standpunkt  vor  und  direkt 
nach  Willan  zuriick. 

Ich  komme  nun  zu  den  neueren  englischen  Autoren  und 
habe  diese  bis  zuletzt  aufgespart,  weil  sie  auf  dem  so  oft  ange- 
deuteten  Wege  der  Reform  des  Rosaceabegriffes  am  weitesten 
fortgeschritten  sind.  Hier  zeigt  uns  die  historische  Betrach- 
tung  das  umgekehrte  Bild  wie  auf  dem  Kontinent  und  in  Nord- 
amerika.  Ausgehend  von  der  allgemeinen  Befangenheit  im 
allzu  weiten  Aknebegriff,  haben  sich  die  Englander  in  ihren 
Hauptvertreten  neuerdings  zu  einer  volligen  Trennung  der 
Rosacea  von  der  Akne  entschlossen.  Tilbury  Fox  (1873)  ist 
noch  iiberzeugter  Anhanger  der  Complicationstheorie.  Er 
sagt:  "  Es  scheint  ziemlich  viel  Unbehagen  in  den  Kopfen  der 
Dermatologen  hinsichtlich  der  Stellung  erzeugt  zu  sein,  welche 
die  Acne  rosacea  in  den  Nosologien  der  verschiedenen  Autoren 
einnimmt.  Doch  ist  die  Sache  im  ganzen  nicht  von  grosser 
Bedeutung,  ob  man  die  Acne  Rosacea  als  Akne  oder  als 
chronische  Hautentziindung  klassifiziert.  Sie  ist :  a  composite 
affair. ' '  Ebenso  spricht  siqh  Jamieson  aus  ( 1888).  Crocker  da- 
gegen  vermeidet  in  seinem^Lehrbuch  (1888),  obwohl  er  die 


DERMATOLOGICAL  CONGRESS  95 

Affektion  Acne  rosacea  betitelt,  prinzipiell  jede  Bezugnahme 
auf  Akne  und  schildert  die  Papeln  und  Pusteln  einfach  als 
begleitende  Talgdrusenentzundungen.  Malcolm  Morris  ( 1894) 
nimmt  auch  nicht  mehr  im  Namen  Bezug  auf  Akne.  Er  nennt 
die  Affektion  einfach  Rosacea,  beschreibt  sie  unter  den  ent- 
zundlichen  Erythemen  und  bewertet  die  Papeln  und  Pusteln 
nur  als  gelegentliche  und  sekundare  Talgdrusenentzundun- 
gen. Noch  deutlicher  und  ausfuhrlicher  in  derselben  Richt- 
ung  spricht  sich  McCall  Anderson  in  seinem  Lehrbuch  (2ste 
Auflage,  1894)  aus.  Er  sagt:  "Die  Rosacea  ist  gewohnlich 
als  eine  Varietat  der  Akne  angesehen  worden;  daher  der 
Name  Acne  rosacea.  Dieser  Irrtum — dessen  Aufdeckung 
wir  Hebra  verdanken — ist  entstanden,  weil  bei  beiden  Affek- 
tionen  das  Gesicht  befallen  ist,  weil  sie  sich  gelegentlich  kom- 
binieren  konnen  und  sich  oft  oberflachlich  ahnlich  sehen. 
Aber,  wie  wir  gleich  sehen  werden,  ist  der  pathologische  Prozess 
vollig  verschieden  von  dem  der  Akne."  Zum  Schlusse  der 
von  der  Akne  vollig  abstrahierenden  klinischen  Schilderung 
gibt  dann  McCall  Anderson  sogar  eine  detaillierte  Differenti- 
aldiagnose  zwischen  Rosacea  und  Akne.  Der  modemste 
unter  alien  Lehrbuchverfassern  ist  aber  ohne  Zweifel  Norman 
Walker  (1899)  und  sein  Buch  zugleich  das  einzige  Lehrbuch, 
in  welchem  meine  vor  20  Jahren  (1887)  aufgestellte  Lehre,  dass 
die  Rosacea  nur  eine  Form  des  seborrhoischen  Ekzems  sei,  vollig 
zum  Durchbruch  gekommen  ist.  Ich  kann  mir  daher  nicht 
versagen,  einen  Passus  aus  Walkers  "  Introduction  to  Der- 
matology" anzufuhren:  "Das  Wort  Akne  in  Verbindung 
mit  der  Rosacea  verliert  taglich  und  verdienterweise  mehr 
und  mehr  seine  Stelle.  Man  wandte  es  an,  weil  haufig 
bei  der  Rosacea  Pusteln  gefunden  werden,  die  eine  ober- 
flachliche  Aehnlichkeit  mit  denen  der  Acne  vulgaris  haben. 
Die  alteren  Lehrbucher  widmeten  den  Unterschieden 
zwischen  beiden  Arten  von  Pusteln  einen  betrachtlichen 1 
Raum,  aber  diese  lassen  sich  leicht  in  der  einen  Tatsache  zusam- 
menfassen,  dass  bei  der  Akne  der  Comedo  der  Ausgangspunkt 
der  Krankheit  und  das  Centrum  jeder  Pustel  bildet,  wahrend 
bei  der  Rosacea  die  Pusteln  sekundar  und  ohne  notwendige 
Beziehung  zu  den  Talgdriisen  sind.  Ohne  ein  neurotisches 

1  Leider  einen  nur  zu  geringen. — U. 


96  SIXTH  INTERNATIONAL 

Element  bei  gewissen  Rosaceaf alien  ableugnen  zu  wollen, 
ist  es  so  gut  wie  gewiss,  dass  die  grosste  Majoritat  aller  Falle 
durch  Seborrhoe  entstehen  und  dass  die  Rosacea  tatsachlich 
eine  Form  der  seborrhoischen  Dermatitis  ist.  Dass  das 
Nervensystem  eine  Rolle  spielt,  ist  richtig,  dass  Magenstor- 
ungen  etc.  die  Affektion  verschlimmern  konnen,  ist  auch 
richtig,  aber  die  wirkliche  Ursache  von  19  unter  20  Fallen  von 
Rosacea  ist  eine  Seborrhoe  des  Kopfes,  indem  sie  durch  die 
bestandige  Reizung  der  Haut  entsteht,  welche  die  Folge 
der  Verschleppung  von  Schuppen  und  Organismen  (?)  der 
Seborrhoe  ist." 

Wir  sehen  mithin,  dass  nirgends  der  Willanismus  grund- 
licher  iiberwunden  ist  als  in  England,  dem  Vaterlande  dessel- 
ben.  Es  geht  mit  der  Rosaceafrage  genau  wie  mit  dem 
Ekzem,  wo  auch  in  England  der  Willan'sche  Ekzembegriff 
der  blaschenformigen  Dermatitis  artificialis  obsolet  ge- 
worden  ist,  wahrend  die  jiingere  franzosische  Bchule  noch 
an  ihm  festhalt  und  beispielsweise  das  seborrhofeche  Ekzem 
deshalb  nicht  als  Ekzem  anerkennt,  weil  es  kein  Blaschen- 
stadium  zeigt  (Brocq). 

Ich  habe,  ohne  damals  zu  wissen,  wie  sehr  ich  dabei  durch 
die  Autoritat  der  besten  alteren  Dermatologen  unterstutzt 
wurde,  bereits  vor  20  Jahren  die  These  aufgestellt, 1  dass  die 
meisten  Falle  von  Rosacea  eine  Krankheit  sui  generis  seien 
und  zwar  eine  Form  des  seborrhoischen  Ekzems.  Damit  hatte 
ich  das  Gros  der  Rosaceafalle  nicht  bloss  vollstandig  dem 
Bereiche  der  Akne  (juvenilis)  entzogen,  sondern  gleichzeitig 
einer  anderen  bekannten  Reihe  von  Krankheitserscheinungen 
einverleibt.  Es  gait  nun,  diese  neue  Synthese  durch  klinische 
Untersuchungen  zu  begninden,2  damit  der  Rosacea  ein  fur 
allemal  eine  ihr  naturliche  Grundlage  zu  geben  und  sie  aus 
der  unnaturlich  gewordenen  Verbindung  mit  der  Akne 
loszulosen.  Wenn  mir  dieses  trotz  des  historisch  begreiflichen, 
aber  allzu  tief  eingewurzelten  Vorurteils  allmahlich  gelungen 
ist,  so  verdanke  ich  dieses  gluckliche  Resultat  hauptsachlich 

dem   Umstande,    dass    die    bessere    atiologische    Erkenntnis 

i 

>  "  Das  seborrhoische  Ekzem,"  Monatshefte  f.  pr.  Derm^Ed.  VI.,  1887. 
2  S.  besonders  die  letzte  Behandlung  dieses  Themas  in  Pathologic  und 
Therapie  des  Ekzems.     Wien,  Holder,  1903,  pg.  199. 


DERMATOLOGICAL  CONGRESS  97 

auch  sofort  eine  Umwdlzung  der  Therapie  der  Rosacea  zur 
Folge  hatte.  Denn  die  so  viel  bespottelte  Nasenrote,  von 
jeher  eines  der  undankbarsten  Gebiete  dermatologischer 
Tatigkeit,  wurde,  sowie  sie  als  ein  "  seborrhoisches  Symptom" 
erkannt  war,  ebenso  leicht  und  radikal  heilbar  wie  die  iibrigen 
Erscheinungen  des  seborrhoischen  Ekzems.  Ich  hatte  daher 
alle  Aerzte  fur  meine  Anschauung  gewonnen,  denen  es  ebenso 
leicht  wie  mir  gelang,  die  Rosacea  definitiv  auf  antiseborrhoische 
Art  zu  heilen. 

Das  Rosaceaproblem  verlangt,  wie  jedes  klinische  Problem, 
das  gewissenhafte  Studium  der  Krankheitsentwicklung  und 
daher  vor  allem  der  fruhesten  Symptome.  Die  Tatsache,  dass 
der  seborrhoische  Ursprung  der  Rosacea  erst  so  spat  auf- 
gefunden  wurde,  erklart  sich  zum  Teil  aus  dem  Umstande, 
dass  die  Patienten  meistens  erst  auf  dem  Hohestadium 
arztliche  Hiilfe  verlangen  und  selbst  iiber  die  ersten  Symp- 
tome keine  Auskunft  geben  konnen.  Dieser  Mangel  driickt 
sich  bezeichnenderweise  auch  darin  aus,  dass  die  besten 
Autoren  absichtlich  keinen  Entwicklungsgang  der  Rosacea 
zeichnen.  F.  Hebra  betont,  dass  er  keine  Stadien,  sondern 
nur  verschiedene,  haufig  vorkommende  "Bilder"  der  Er- 
krankung  geben  wolle,  und  nennt  als  solche  vier:  eine  blau- 
liche  Rote  der  Nasenspitze,  ahnlich  einer  Erfrierung;  sodann 
Rote  mit  Fettglanz  und  periodischer  Steigerung  nach  der 
Mahlzeit;  weiter  grobere  Gefasserweiterungen  und  endlich 
gewohnliche  Talgdriisenentzundungen,  von  denen  ubrigens 
nur  die  drei  letzteren  der  seborrhoischen  Rosacea  angehoren. 
Kaposi  allerdings  gab  diese  einsichtsvolle  Beschrankung  auf 
und  construierte  ad  usum  delphini 1  drei  Grade  der  Erkrankung : 
(i)  Rotung  der  Nasenspitze,  (2)  rote  Knoten  und  Angiek- 
tasien,  (3)  Rhinophym.  Aber  in  der  franzosischen  Ueber- 
setzung  von  Kaposi  bricht  sich  doch  wieder  die  bessere 
Einsicht  Bahn,  und  anmerkungsweise  gibt  Besnier  wiederum 
der  Ansicht  Ausdruck,  dass  man  keine  Stadien,  sondern  nur 
verschiedene  Formen  der  Rosacea  unterscheiden  konne  und 
zwar:  ein  glattes  Erythem,  ein  seborrhoisches  Erythem,  ein 

» Vgl.  hierzu  die  eigenttimliche  Umstellung  der  Hebra'schen  Ekzem- 
stadien  durch  Kaposi  filr  seine  Vorlesungen :  Unna,  Pathologic  und  Therapie 
des  Ekzems.  Holder,  Wien  1903,  pg.  81. 


VOL.  i. — 7 


98  SIXTH  INTERNATIONAL 

tiefreichendes  Erythem  mit  Papeln,  die  Teleangiektasien 
und  das  Rhinophym.  In  der  Tat  wachst  das  Krankheitsbild 
der  Rosacea  aus  sehrverschiedenen  einzelnen  Elementen  zusam- 
men,  die  in  ihrer  Besonderheit  nur  im  Anfange  der  Krankheit 
richtig  erkannt  werden.  Man  muss  daher  die  Rosacea  schon 
fruher  studieren  als  sie  zum  Arzte  kommt.  Dazu  gehort,  dass 
man  fleissig  die  Gesichter  von  Gesunden  studiert,  und  das 
kann  man  am  besten  dort,  wo  Menschen  langere  Zeit  ruhig 
zusammen  sitzen;  allerdings  sind  Theater,  Concerte  und 
Gesellschaften  nicht  der  rechte  Ort,  denn  dort  sind  grade 
die  Gesunden,  auf  die  es  ankommt,  durch  Puder  und  andere 
Behelfe  in  unnaturlicher  Weise  verschont.  Aber  die  Eisen- 
bahnen,  Pferdebahnen,  elektrischen  Barmen,  Omnibusse,  etc. 
bieten  dem  aufmerksamen  Beobachter  eine  interessante,  nie 
versiegende  Quelle  der  Belehrung.  Hier  findet  man  im  Laufe 
der  Zeit  alle  Anfangssymptome  der  Rosacea  einzeln  auf  und 
erkennt  schliesslich  mit  unfehlbarer  Sicherheit  die  Candidaten 
einer  spateren,  ausgepragten  Rosacea  aus  alien  ubrigen 
Menschen  heraus.  Allerdings  sind  die  ersten,  unscheinbaren 
Symptome,  die  noch  in  die  Breite  sogenannter  Gesundheit 
fallen,  sehr  vielgestaltig ;  aber  es  kehren  doch  gewisse  Zuge 
immer  wieder.  Unter  diesen  hebe  ich  einen  als  den  ersten 
hervor,  weil  er  nicht  nur  sehr  charakteristisch,  sondern  auch 
bisher  noch  nirgends  beschrieben  ist,  das  ist  die  Vergilbung 
der  Haut  in  der  Umgebung  von  Nase  und  Mund.  Mit  diesem 
Namen  habe  ich  eine  eigentumliche  Gelbfarbung  der  Haut 
bezeichnet,  die  ein  Kennzeichen  des  seborrhoischen  Ekzems 
ist. 1  Wo  sie  als  friihes  Zeichen  beginnender  Rosacea  auftritt, 
befallt  sie  die  Ober-  und  Unterlippen  und  schneidet  nach 
aussen  in  scharfer  Linie  mit  der  Nasolabialfurche,  nach  unten 
mit  der  Kinnfurche  ab.  Die  gelbliche  Farbung  dieser  Haut- 
partie  springt  um  so  mehr  in  die  Augen,  weil  die  nachste 
Umgeben  in  starkem  Contraste  dazu  eine  rote  Farbung 
aufweist,  besonders  die  Hohe  der  Nasolabialfalten,  haufig 
auch  die  Nase  und  das  Kinn.  Wahrend  die  weitere  Umge- 
bung der  Nase  und  Wangen  in  diesem  Fruhstadium  zuweilen 
schon  ein  recht  buntscheckiges  Aussehen  gewahrt,  fallt  die 

>  Unna,  Pathologic  und  Therapie  des  Ekzems.      Hdlder,   Wien,   1903. 
Pg-  i75- 


DERMATOLOGICAL  CONGRESS  99 

nachste  Umgebung  von  Nase  und  Mund  durch  ihre  matte, 
gelblich-bleiche  Farbe  und  die  Abwesenheit  roter  Flecken  auf . 
In  vielen  Fallen  bleibt  diese  lokale  Anamie  und  Vergilbung 
der  Lippen  auch  dann  noch  bestehen,  wenn  die  Rosacea  ihren 
Hohepunkt  erreicht  hat  und  fast  das  ganze  iibrige  Gesicht 
einnimmt.  Doch  werden  in  anderen  Fallen  diese  scharfen 
Grenzen  mit  dem  Fortschreiten  der  Rosacea  verwischt. 

Ein  zweites  Fruhsymptom,  allerdings  schon  bekannt,  aber 
doch.nur  sehr  selten  (so  von  Besnier)  bei  der  Rosacea  erwahnt, 
ist  die  Pityriasis  alba  faciei.  Hierunter  verstehen  wir  schil- 
fernde  Flecke  von  Linsen-  bis  Markstuckgrosse,  welche 
hauptsachlich  die  untere  Wangengegend,  aber  auch  Kinn, 
Nase  und  Stirn  einnehmen.  Hin  und  wieder  konfluieren 
dieselben  zu  grosseren  mattweissen  oder  grauen,  schilfernden 
Flachen.  Diese  Form  des  seborrhoischen  Ekzems  kommt 
haufig  ganz  fur  sich  allein  vor,  am  meisten  bei  jugendlichen 
Personen,  gruppenweise  sogar  in  Familien  und  Schulen  bei 
Kindern.  Bildet  sie  mit  anderen  Erscheinungen  den  Anfang 
einer  Rosacea,  so  tritt  sie  nicht  so  deutlich  wie  sonst  in  die 
Erscheinung,  da  die  hier  und  da  auftretenden  roten  Flecke 
die  Aufmerksamkeit  mehr  auf  sich  ziehen  und  hin  und  wieder 
auch  mit  den  schilfernden  Flecken  zusammenf alien,  sodass 
dann  rote,  abschuppende  Stellen  entstehen.  Die  Patienten, 
meistens  Frauen,  die  sich  besser  beobachten,  wissen  manchmal 
anzugeben,  dass  sie  die  blassen,  schuppenden  Stellen,  die 
von  ihnen  fur  eine  besondere  Art  "  Sprodigkeit "  gehalten 
wurden,  schon  lange  vor  dem  Beginn  der  roten  Flecke 
besassen. 

Im  Gegensatz  zu  diesen  Symptomen  geht  die  olige 
Seborrhoe  der  Nase  haufig  der  beginnenden  Rosacea  alterer 
Patienten  mannlichen  Geschlechts  voran.  Die  olige  Se- 
borrhoe der  Pubertat,  insbesondere  die  der  jungen  Madchen, 
verbindet  sich  im  allgemeinen  nicht  mit  der  Rosacea,  sondern 
mit  Anamie  der  Nasenhaut  und  haufig  auch  mit  der  wahren 
Akne.  Auch  ist  die  Form  der  Rosacea,  die  bei  bejahrten 
Mannern  zur  Seborrhoe  oleosa  hinzutritt,  nicht  die  gewohn- 
liche  Form  der  roten  Flecke,  sondern  besteht  zunachst  in 
einfachen  Venenektasien  und  Netzen  solcher.  zu  denen  sich 
erst  spater  einzelne  erythematose  Flecke  gesellen. 


ioo  SIXTH  INTERNATIONAL 

Wir  kommen  nun  zu  derjenigen  Angiektasie,  welche,  wenn 
sie  auch  nur  selten  das  erste  Symptom  darstellt,  doch  als 
das  Hauptsymptom  die  Rosacea  beherrscht.  Erst  durch  das 
Hinzutreten  dieser  Gefasserweiterung  werden  die  genannten 
'Friihsymptome,  die  auch  alle  fur  sich  bestehen  konnen, 
zur  seborrhoischen  Rosacea.  Die  Wichtigkeit  dieses  Symp- 
toms verlangt,  dass  wir  uns  griindlicher  als  es  meistens  bisher 
geschehen  ist  mit  seinen  Besonderheiten,  seiner  anatomischen 
und  physiologischen  Grundlage  beschaftigen.  Das  Typische 
dieser  Gefasserweiterung  der  Haut  liegt  bekanntlich  in  der 
Lokalisation,  in  ihrer  Beschrankung  auf  die  mittlere  Partie 
des  Gesichtes,  die  Nase,  Wangen  und  nachstbelegenen 
Bezirke  von  Kinn  und  Stirn.  Diese  sind  aber  bekanntlich 
auch  diejenigen  Stellen  der  Haut,  welche  bei  der  weissen 
Rasse  zu  einer  physiologischen  Hyperamie  pradisponiert  sind. 
Je  kuhler  das  Klima  und  je  pigmentloser  die  Gesichtshaut, 
um  so  reiner  tritt  diese,  "  normale  Angioparese"  der  Gesichts- 
haut in  die  Erscheinung  derart,  dass  ein  zartes  Rot  der 
mittleren  Wangenpartie  uns  nicht  nur  normal,  sondern  der 
Mangel  eines  solchen  unschon  erscheint.  Trotzdem  miissen 
wir  auch  diese  "normale  Rote"  als  eine  allerdings  leichte 
Gefassparese  bezeichnen  und  auf  das  Konto  des  kiihlen 
Klimas  setzen.  Denn  der  ebenso  weisse,  pigmentlose  Euro- 
paer  zeigt  in  sudlichen,  warmeren  Teilen  Europas  dieses 
Incarnat  weniger  oder  garnicht.  Diese  Rotung  der  her- 
vortretenden  Teile  des  Gesichtes  bildet  die  naturliche  Reak- 
tion  auf  den  vorangehenden  Kaltereiz,  der  zunachst  zwar 
eine  Kontraktion  der  Arterien  bewirkt,  auf  welche  aber 
noch  wahrend  der  Fortdauer  des  Kaltereizes  der  fiir  die  Haut 
wohltatige  Umschlag  in  eine  Wallungshyperamie  folgt. 
Trifft  dieser  Umschlag  zeitlich  zusammen  mit  dem  Ersatz 
der  ausseren  Kalte  durch  Warme,  wie  z.  B.  beim  Eintritt  in 
ein  geheiztes  Zimmer  aus  der  winterlichen  Kalte,  so  nimmt 
die  Parese  der  Hautgefasse  einen  sehr  hohen  Grad  an — 
das  Gesicht  gluht.  Dieser  allbekannte  Vorgang  bildet  das 
physiologische  Vorbild  fiir  die  stets  pathologische  Erscheinung 
der  Rosacea,  wie  er  denn  auch  wesentlich  verschlimmernd 
in  den  Process  dieser  Krankheit  eingreift.  Der  dauernde 
Mangel  starker  Kaltereize  im  sudlichen  Europa  fuhrt 


DERMATOLOGICAL  CONGRESS  101 

ebenso  notwendig  als  Reaktion  einen  dauernden  starken 
Tonus  der  Hautgefasse,  eine  habituelle  Blasse  herbei. 
Hardy  hatte  also  vollkommen  recht,  wenn  er  zum  ersten  Male 
darauf  hinwies,  dass  die  Rosacea  eine  Krankheit  der  kalten 
Lander,  besonders  Englands  und  Russlands  sei,  und  wir 
verstehen  auch,  dass  uns  weder  Griechen  und  Romer  noch 
Araber  Schilderungen  der  Rosacea  hinterlassen  haben,  dass 
diese  Affektion  aber  wohl  im  Mittelalter  bekannt  wurde,  als 
die  medizinische  Wissenschaft  an  die  nordlichen  Volker 
Europas  iiberging.  Die  Kalte  mit  ihrer  Folge  der  sekund- 
aren  Gefassparese  ist  aber  stets  nur  eine  accidentelle  Ursache 
der  seborrhoischen,  eigentlichen  Rosacea.  Wir  werden 
hierauf  noch  bei  der  Differentialdiagnose  zwischen  der  Rosacea 
und  dem  Frost  (Perniosis)  der  Nase  zuruckkommen,  welchen 
viele  Autoren  auch  Rosacea  (Couperose)  genannt  haben,  und 
bei  welchem  die  Kalte  den  hauptsachlichen,  den  zureichenden 
Grund  abgibt. 

Wir  konnen  mithin  die  eigentumliche  Lokalisation  der 
Rosacea  durch  diese  der  Gesichtshaut  eigene  Neigung  zur 
Gefassparese,  zur  Blutwallung  erklaren,  welche  zunachst 
durch  aussere  Temperaturschwankungen  erworben  und  dann 
in  den  Dienst  vieler  anderen,  inneren  Nervenreize  gestellt 
wurde.  Hiermit  sind  aber  noch  nicht  alle  Eigentumlich- 
keiten  dieser  Angiektasie  erschopft.  Denn  eine  Parese  der 
Hautarterien  erklart  durch  die  mit  Sicherheit  folgende 
Blutiiberfullung  des  oberflachlichen  Kapillarnetzes  wohl  die 
diffuse  Rote  der  Nase  und  Wangen,  aber  noch  nicht  die 
eben  falls  fur  die  Rosacea  so  charakteristischen  und  noch 
viel  auffallenderen  Erweiterungen  und  Schlangelungen  der 
Hautvenen.  Ganz  unerklarlich  aber  erscheinen  auf  den 
ersten  Blick  diese  varikosen  Venennetze  dort,  wo  garnicht 
einmal  eine  starke  diffuse  Hautrote  konkurriert,  die  Kapillaren 
mithin  wenig  oder  garnicht  erweitert  sind,  wie  so  oft  bei 
der  Rosacea  der  alteren  Herren.  Fur  diese  Erscheinungen 
geniigt  offenbar  das  einfache  Schema  der  Gefassparese  nicht, 
und  wir  mussen  uns  nach  lokalen  Besonderheiten  in  der 
Anlage  der  Hautgefasse  umsehen.  Diese  kennen  wir  aller- 
dings  genauer  nur  fur  die  Nasenhaut;  die  Beschreibung  von 
Luschka  stimmt  mit  den  ausgezeichnet  guten  Abbildungen 


102 

in  dem  vortrefflichen  alt  en  Atlas  von  Friedrich  Arnold  gut 
uberein.  Bekanntlich  entbehrt  die  Nasenhaut  fast  voll- 
standig  des  subkutanen  Fettgewebes,  ist  auf  dem  Nasen- 
fliigel  und  der  Nasenspitze  fest  mit  der  teils  knorpligen, 
teils  fibrosen  Unterlage  verwachsen  und  nur  auf  dem  oberen 
und  seitlichen  Teil  der  Nase  verschieblich.  Die  Arterien 
stromen  reichlich  von  alien  Seiten  (von  der  Maxillaris  externa 
und  interna  und  Ophthalmica)  zu  und  bilden  zwischen  Haut 
und  Muskulatur,  also  dort,  wo  sonst  der  Panniculus  sich 
befindet,  ein  grobes,  ziemlich  dichtes  Netz.  Dieses  entspricht 
dem  an  der  Cutis-Subcutisgrenze  sich  ausbreitenden  Netz 
anderer  Hautstellen  (z.  B.  der  Vola  manus),  ist  aber  viel 
reicher  ausgebildet.  Aus  diesem  tiefen  arteriellen  '  Netz 
erheben  sich  die  kapillaren  Gefasse  der  Nasenhaut  und  bilden 
ein  zweites,  feineres  Netz  unterhalb  der  Oberhaut.  Inso- 
weit  gleicht  das  Schema  der  Gefasse  der  Nasenhaut  dem 
gewohnlichen  Schema  der  Hautgefasse.  Nun  kommt  aber 
eine  Besonderheit,  welche  wohl  mit  der  straff  en  Anheftung 
der  Nasencutis  an  die  Unterlage  zusammenhangt.  Normal- 
erweise  namlich  nehmen  die  Venen  denselben  Weg  zuruck, 
den  die  Arterien  genommen  haben,  und  entwickeln  sich  aus 
demselben  oberflachlichen  Kapillarnetz,  indem  die  grosseren 
venosen  Kapillaren  sich  den  cutanen  und  subcutanen  Arterien 
anschliessen,  sodass  die  grossen  Hautvenen  wieder  ebenso  tief 
gelagert  sind  wie  die  Arterien  desselben  Kalibers.  An  der 
Nasenhaut  weichen  aber  die  grosseren  Venen  nach  aussen 
ab;  sie  sind  auf  derselben  Hohe  wie  das  Kapillarnetz  in  die 
Cutis  eingebettet,  bilden  zwischen  den  Kapillaren  ein  sehr 
weitmaschiges  Netz  und  liefern  ihr  Blut  auf  oberflachlichem 
Wege  in  die  Facialis  anterior  und  die  Coronaria  lab.  sup. 
Man  kann  also  den  Blutverlauf  kurz  so  beschreiben,  dass 
die  Nasenhaut  ihr  Blut  durch  ein  dichtes  Netz  von  unten 
empfangt  und  es  nach  Auflosung  der  Arterien  in  ein  Kapil- 
larnetz durch  ein  weites  Venennetz  nach  aussen  wieder  abgibt. 
Diese  seltsam  hochgelagerten  groben  Venen  erkennt  man  schon 
bei  manchen  Gesunden  bei  starkerer  Blutfiille  an  den  Nasen- 
fliigeln,  wo  sie  in  parallelem  Verlaufe  den  Knorpel  des  Nasen- 
fliigels  queren ;  auch  sieht  man  sie  sehr  deutlich  auf  dem  Bild 
der  Nasenvenen  von  Arnold.  Sie  sind  es,  die  bei  der  eben 


DERMATOLOGICAL  CONGRESS  103 

erwahnten  beginnenden  Rosacea  alterer  Herren  manchmal 
allein  erweitert  sind  und  welche  bei  jeder  Heilung  einer  ge- 
wohnlichen  langer  bestehenden,  diffus  roten  Rosacea  zuletzt 
ubrig  bleiben  und  einzeln  entfernt  werden  mussen. 

Aus  dieser  Schilderung  sieht  man  deutlich,  dass  die  ge- 
wohnliche  Darstellung,  als  seien  die  Teleangiektasien  und 
die  diffuse  Wallungshyperamie  getrennt  fur  sich  bestehende 
Symptome  der  Rosacea,  nicht  haltbar  ist.  Sowohl  die  diffuse 
Hyperamie  des  oberflachlichen  Kapillarnetzes  wie  die  Ektasie 
der  im  selben  Niveau  liegenden  grossen  Venen  sind  gleich- 
wertige  Folgen  einer  fiir  gewohnlich  nicht  zu  Tage  treten- 
den  Parese  des  tiefen  arteriellen  Gefassnetzes.  Gewohnlich 
erweitern  sich  beide  Teile  des  abfuhrenden  Gefasssystems 
gleichzeitig.  Bleibt  aus  irgend  welchen  Griinden — und  wir 
werden  solche  kennen  lernen  —  die  oberflachliche  Kapillar- 
hyperamie  aus,  so  tret  en  allein  die  verbreiterten  oder  auch 
verlangerten  und  dann  geschlangelten  grossen  Venen  in  die 
Erscheinung.  Daraus  ist  dann  aber  keineswegs  auf  eine 
primare  Gefasshypertrophie  zu  schliessen,  wie  sie  Auspitz 
einen  Gedankengang  des  alteren  Hebra  fortsetzend,  ange- 
nommen  hat.  Es  entwickelt  sich  einfach  unter  unseren 
Augen  ein  Vorgang  an  der  Oberflache  der  Haut,  der  uns  sonst 
durch  seine  subkutane  Lage  entgeht  und  der  als  eine  dauernde 
Parese  des  Arteriennetzes  mit  ihren  Folgen  zu  definieren  ist. 

Leider  fehlt  uns  eine  entsprechende  Klarheit  tiber  die 
Gefassversorgung  der  mittleren  Wangenpartie.  Wir  wissen 
nicht  ob  die  auch  hier  so  haufig  auftretenden  und  auffallenden 
Venenektasien,  Venennetze  und  Venensterne  ebenfalls  wie 
in  der  Nasenhaut  einer  abnormen  Hochlagerung  der  Venen 
innerhalb  der  Cutis  ihr  Dasein  verdanken.  Es  ware  verdienst- 
lich,  durch  Injectionspraparate  der  Wangenhaut,  insbesondere 
bei  alteren  Leuten,  diese  Frage  zu  beantworten. 

Sind  nun  die  besprochenen  Kapillar-  und  Venenektasien 
der  Gesichtshaut  die  blosse  Folge  periodischer,  immer  wieder- 
kehrender  Hyperamien  der  Gesichtshaut?  Konnen  einfache 
Blutwallungen  zum  Kopfe  allmahlich  das  Gesamtbild  der 
Rosacea  zur  Folge  haben?  Durchaus  nicht.  Da  liegt  eben 
der  alte  und  allgemeine  Fehler,  der  sich  durch  die  atiologischen 
Erorterungen  der  meisten  Lehrbiicher  hindurchzieht.  Man 


I04  SIXTH  INTERNATIONAL 

beschuldigte  alle  moglichen  inneren,  lokalen  und  konstitution- 
ellen  Leiden,  dass  sie  auf  dem  Wege  des  Nervenreflexes  Blut- 
wallungen  zum  Kopfe  hervorriefen  und  glaubte  damit  schon 
eine  Basis  zum  Verstandnisse  der  Rosacea  gefunden  zu  haben, 
iibersah  aber  vollkommen,  dass  es  viele  Menschen  gibt,  die 
an  habituellen  Congestionen  des  Kopfes  leiden,  ohne  auch  nur 
den  Beginn  einer  Rosacea  zu  zeigen.  Nur  diejenigen  unter 
ihnen  erwerben  mit  der  Zeit  eine  Rosacea,  welche  bereits 
vorher  gereizte,  erkrankte  Partien  der  Gesichtshaut  besassen. 
Und  in  solchen  Fallen  ist  es  dann  allerdings  augenscheinlich, 
dass  sowohl  die  Ausbreitung  wie  die  Starke  der  Hautaffek- 
tion  unter  dem  Einflusse  der  periodisch  wiederkehrenden 
Blutwallungen  rascher  und  bedeutender  zunimmt  als  sie  es 
ohne  diesen  befordernden  Umstand  tun  wurden.  Auch 
tragen  periodische  Wallungen  dazu  bei,  dass  die  ursprunglich 
zerstreuten  Herde  der  Erkrankung  allmahlich  zu  einer 
gleichmassigen,  diffusen  Rote  konfluieren,  aber  notwendig 
sind  sie  in  keinem  Falle. 

Die  im  Anfang  beobachtete  Rosacea  tritt  stets  fleckweise  auf, 
und  es  ist  durchaus  nicht  immer  die  Nasenspitze,  wie  manche 
Autoren  angeben,  die  zuerst  befallen  wird.  Von  den  so 
charakteristischen  Rotungen  der  Wangen,  welche  streifen- 
formig  die  vergilbten  Nasolabialfalten  umgeben,  ist  schon 
die  Rede  gewesen.  Haufiger  treten  aber  zerstreut  an  den 
Wangen,  der  Nase  und  Stirn,  urn  den  Mund  herum  linsen- 
grosse  und  grossere  Flecke  von  frisch  roter  Farbe  auf.  Diese 
vergehen  oft,  um  bald  darauf  an  derselben  Stelle  oder  anderen 
Orten  wieder  zu  erscheinen.  Sie  verursachen  nur  eine  leichte 
brennende  oder  juckende  Empfindung;  oft  fehlt  dieselbe  ganz. 
Untersucht  man  die  Flecke  genauer,  so  findet  man  im  Cen- 
trum oft  einen  dunkler  geroteten  Punkt,  oder  eine  follikulare 
Erhebung,  ja  hin  und  wieder  eine  kleine  Papel  mit  gelblichem 
Kopf.  Allmahlich  fassen  die  Flecke  festen  Fuss,  benach- 
barte  konfluieren  zu  grosseren  roten  Flachen;  man  findet 
jetzt  z.  B.  eine  diffuse  Rote  um  beide  Nasenlocher,  an  der 
Nasenwurzel,  auf  einer  oder  beiden  Backen,  daneben  aber 
noch  mehrere  vereinzelte  rote  Flecke.  Die  zwischen  diesen 
zerstreuten  Herden  liegende  Haut  ist  nicht  normal,  sondern 
streckenweise  schuppig  und  vergilbt,  besonders  bei  jungeren 


DERMATOLOGICAL  CONGRESS  105 

Leuten,  fettig  und  vergilbt  ofter  bei  alteren.  Dazwischen 
treten  Venenektasien  auf  und  mehren  sich  mit  dem  Alter. 
Sie  zeichnen  meist  die  diffus  geroteten  Stellen  aus  und  ver- 
leihen  denselben  ein  noch  dunkleres  Colorit,  aber  sie  erscheinen 
auch  auf  blassgelber  Haut,  wie  schon  oben  bemerkt.  Es 
handelt  sich  dann  gewohnlich  um  solche  Hautstellen,  welche 
durch  Talgdriisensekret  stark  eingefettet  sind  und  wo 
wegen  einer  gleichzeitigen  Hypertrophie  der  Talgdriisen 
das  erweiterte  Kapillarnetz  in  ein  tieferes  Hautniveau  zu 
liegen  kommt,  womit  die  diffuse  Rote  der  Oberflache  ver- 
schwindet.  Daher  charakterisieren  die  Venennetze  auf  gelb- 
licher,  fettiger  Haut  gewohnlich  altere  Leute  mannlichen 
Geschlechts. 

Aus  dieser  Beschreibung  ist  ersichtlich,  dass  der  alte, 
aus  dem  Mittelalter  herruhrende  Name  Gutta  rosea,  rosen- 
farbener  Tropfen,  eigentlich  sehr  bezeichnend  war.  Das 
Fleckige,  das  Bunte  ist  fur  den  der  Rosacea  anheimfallenden 
Teint  das  Charakteristische.  Die  einformige  Rote  ist  erst 
ein  sekundares  Phanomen,  welches  nur  diejenigen  Falle 
von  Rosacea  aufweisen,  welche  viel  an  aufsteigender  Hitze,  an 
Wallungen  zum  Kopfe  leiden,  oder  bei  denen  eine  verkehrte 
ausserliche  Behandlung  eine  universelle  Gesichtsrote  zu- 
wege  gebracht  hat. 

Wesentlich  verstarkt  wird  die  bunte  Beschaffenheit  der 
Haut  nun  noch  weiter  durch  das  Auftreten  jener  Follikulitiden, 
iiber  deren  verschiedene  Deutung  ich  im  historischen  Teile 
gesprochen  habe.  Auch  die  Follikulitiden  konnen  ein  pri- 
mares  Symptom  sein,  an  welches  sich  erst  spater  die  Gesichts- 
rote anschliesst,  meistens  aber  finden  wir  sie  erst  im  Ver- 
laufe  der  Rosacea  und  in  jedem  Falle  in  verschiedener  Starke 
und  Menge.  Es  gibt  Rosaceafalle,  welche  auch  bei  jahrzehn- 
telangem  Verlaufe  keine  follikularen  Entzundungen  aufweisen 
und  daher  auch  nie  die  geringste  Handhabe  bieten,  etwas 
"  Akneartiges "  anzunehmen.  Aber  die  meisten  Falle  zeigen 
schon  fruh,  manche  vom  Beginne  an  Papeln  und  Pusteln. 
Gewohnlich  bilden  dieselben  das  Centrum  roter  Flecke, 
konnen  aber  auch  isoliert  vorkommen.  Im  Gegensatz  zu 
den  Papeln  und  Pusteln  der  (echten  juvenilen)  Akne  haben 
diejenigen  der  Rosacea  vier  charakteristische  Eigenschaften, 


106  SIXTH  INTERNATIONAL 

welche  sie  bei  aufmerksamer  Beobachtung  stets  sicher  erkennen 
lassen:  (i)  den  Mangel  an  Comedonen,  (2)  den  oberflach- 
lichen  Sitz,  (3)  den  haufigen  und  raschen  Wechsel  der  Er- 
scheinung  und  (4)  die  relative  Schmerzlosigkeit.  Zu  diesen 
Eigenschaften  der  einzelnen  Follikulitiden  kommt  noch  fur 
das  Gesamtbild  (5)  die  Verschiedenheit  der  Verteilung  der 
Effloreszenzen  uber  das  Gesicht  bei  beiden  Affektionen. 

Der  fundamentalste  Unterschied  zwischen  einer  Pustel 
der  Rosacea  und  einer  Aknepustel  besteht  darin,  dass  die 
letztere  sich  auf  der  Struktur  eines  Komedos  aufbaut,  die 
erstere  nicht.  Einer  Acne  pustulosa  ist  stets  eine  Acne 
punctata  vorausgegangen,  die  lediglich  durch  die  Komedonen 
und  eine  allgemeine  Hyperkeratose  der  Oberflache  char- 
akterisiert  ist.  Freilich  muss  man  in  Bezug  auf  den  Komedo 
alle  laxen  Bezeichnungen  vermeiden  und  scharf  definieren. 
Ein  Komedo  ist  ein  projektilartiges,  im  Innern  segmentiertes 
Hornkorperchen  mit  einem  Inhalt  von  Fett  und  Aknebazillen, 
welches  nach  unten  entweder  often  oder  auch  durch  Horn- 
schicht  geschlossen  ist.  Es  ist  erzeugt  durch  eine  Hyper- 
keratose des  Ausfuhrungsganges  einer  Talgdruse  oder  eines 
Haarbalges  und  pathognomonisch  fur  die  Akne.  Nicht  mit 
Komedonen  zu  verwechseln — was  leider  haufig  geschieht — 
sind  die  schwarzen  Punkte,  welche  die  Ausfuhrungsgange 
offner,  talgerfullter,  erweiterter  Talgdriisen  markieren  und 
beim  Ausdrucken  den  dunkeln  Kopf  einer  einfachen  Talg- 
masse  darstellen ;  wir  nennen  sie  die  Punktation  der  Talgdriisen. 
Da  wir  im  hornigen  Komedo  ein  sehr  scharf  definierbares 
Naturprodukt  vor  uns  haben,  kann  es  immer  nur  zur  Kon- 
fusion  fiihren,  wenn  wir  eine  beliebig  in  Wurmform  aus- 
driickbare  Talgmasse  mit  demselben  Namen  benennen,  auch 
wenn  ihr  Kopf  dunkel  gefarbt  ist.  So  konstant  der  Komedo 
bei  der  Akne  als  Kern  der  Affektion  zu  finden  ist,  so  konstant  fehlt 
er  bei  der  Rosacea,  wenn  auch  eine  Punktation  besonders  auf 
der  Nase  bei  der  letzteren  hin  und  wieder  vorkommt. 

Die  Papeln  und  Pusteln  der  Rosacea  ergeben  also  beim  Aus- 
drucken keine  Komedonen.  Es  lasst  sich  auch  aus  den  Pusteln 
nur  wenig  eitriges  Exsudat  gewinnen,  da  dieselben  nie  so  gross 
sind  und  so  tief  reichen  wie  die  Aknepusteln.  Die  meisten 
Papeln  der  Rosacea  bilden  sich  uberhaupt  nicht  in  Pusteln  um 


DERMATOLOGICAL  CONGRESS  107 

und  konnen  die  Dimensionen  einer  Erbse  oder  Linse  erreichen, 
ohne  etwas  Anderes  darzustellen  als  trockne,  rote,  indolente 
Protuberanzen.  Niemals  schliesst  sich  ferner  an  die  Pusteln 
der  Rosacea  eine  so  tiefgehende  Infiltration  und  weitgehende 
eitrige  Zers toning  der  Cutis  an  wie  bei  Aknepusteln,  weshalb 
auch  die  narbigen  Verunstaltungen  der  Akne  selbst  bei  lang- 
jahrigem  Bestande  der  Rosacea  stets  fehlen.  Dagegen  haben 
die  Papeln  der  Rosacea  die  Neigung,  sich  rascher  in  der 
Flache  auszubreiten  und  starker  uber  die  Oberflache  zu  er- 
heben.  Haufig  heilen  die  Papeln  und  Pusteln  nach  kurzem 
Bestande  von  selbst  ab,  um  allerdings  ebenso  haufig  an 
derselben  Stelle  oder  daneben  wieder  aufzutreten.  Ein  so 
hartnackiges,  monatelanges  Verbleiben  der  Effloreszenzen  an 
derselben  Stelle  wie  bei  gleich  grossen  Aknepusteln  kommt 
bei  der  Rosacea  nicht  vor  oder  ist  wenigstens  sehr  selten. 
Durch  diesen  oberflachlichen  Sitz,  die  raschere  Abwandlung 
der  Einzeleffloreszenzen  und  ihren  haufigen  Ortswechsel  wird 
das  Gesamtbild  der  pustulosen  Rosacea  ein  viel  fluch- 
tigeres  und  wechselnderes  als  das  der  pustulosen  Akne. 
Durch  die  oberflachlichere  Lage,  die  geringere  Eiterung  und 
die  mangelnde  Zerstorung  der  Cutis  erklart  sich  auch  von 
selbst  die  geringere,  oft  ganz  fehlende  Schmerzhaftigkeit  der 
pustulosen  Rosacea.  An  subjektiven  Empfindungen  wird 
hochstens  uber  geringes  Brennen  und  Jucken  geklagt. 

Aus  alien  diesen  klinischen  Daten  muss  man  fur  die 
betreffenden  parasitaren  Keime  beider  Affektionen  den  Schluss 
ziehen,  dass  die  der  Rosacea  nicht  so  tief  in  die  Follikel  ein- 
dringen,  die  Leukocyten  weniger  stark  anlocken,  selbst  rascher 
proliferieren  und  rascher  an  Ort  und  Stelle  wieder  absterben 
als  die  der  Akne. 

Zu  den  genannten  Verschiedenheiten  zwischen  den  Folli- 
kulitiden  der  Rosacea  und  derien  der  Akne  kommt  nun  schliess- 
lich  noch  die  ganz  verschiedene  regionare  Verbreitung  beider 
Affektionen.  Schon  Rayer  machte  darauf  aufmerksam,  dass 
die  "Couperose"  auf  das  Gesicht  beschrankt  sei,  wahrend 
die  Akne  auch  den  Riicken  befallt.  Jetzt  ist  es  allgemein 
bekannt,  dass  ausser  diesen  Regionen  auch  die  obere  Partie 
der  Brusthaut  mit  Vorliebe  von  der  Akne  befallen  wird,  ja, 
dass  in  manchen  Fallen  der  ganze  Rumpf  und  die  oberen 


io8  SIXTH  INTERNATIONAL 

Partien  der  Oberarme  ergriffen  werden.  Im  Gesicht  selbst 
treffen  aber  die  Pradilektionsstellen  auch  nur  teilweise  auf 
Nase  und  Wangen  zusammen.  Die  Stirnhaargrenze  und  die 
seitlichen  Teile  der  Wangen,  welche  die  Akne  mit  Vorliebe 
einnimmt,  werden  von  der  Rosacea  gewohnlich  frei  gelassen. 
Letztere  befallt  haufig  die  Nasenspitze,  die  Akne  die  Con- 
cavitat  der  Ohrmuschel,  nicht  auch  umgekehrt.  I.  Neumann 
machte  zuerst  mit  Recht  darauf  aufmerksam,  dass  die  Rosacea 
auch  die  Glatzen  befallt.  In  der  Tat  ist  es  ein  sehr  charak- 
teristisches  Bild,  welches  die  Rosacea  alterer  Manner  liefert, 
indem  die  fleckige  Rote  des  Antlitzes  sich  uber  die  Stirn 
bis  auf  die  Mitte  des  kahlen  Scheitels  hinaufzieht.  Niemals 
geht  die  Akne  so  weit  uber  die  Stirnhaargrenze  aufwarts. 

Aus  den  besprochenen  sechs  Elementen  der  Pityriasis 
alba,  der  Vergilbung,  der  Kapillarerweiterungen  und  Varicen, 
der  Papeln  und  Pusteln  setzen  sich  nun  in  allerverschiedenster 
Weise  die  bunten  Bilder  der  Rosacea  zusammen.  Im  all- 
gemeinen  wiegen  die  erstgenannten  Symptome  im  Anfange, 
die  letztgenannten  spater  vor.  Doch  gibt  es  Falle,  die  zeit- 
lebens  nur  wenige  rote  Flecke  aufweisen.  Die  sich  gewohnlich 
mit  den  Jahren  mehr  und  mehr  ausbreitende  Kapillarek- 
tasie  macht  aber  das  Aussehen  der  Patienten  schliesslich 
wieder  gleichformiger.  Dass  man  keine  festen  Formen  oder 
Grade  der  Erkrankung  aufstellen  kann,  ergibt  sich  hieraus 
von  selbst. 

Ein  gliicklicherweise  seltener  Ausgang  der  Rosacea  ist 
der  in  Rhinophym.  Hierunter  verstehen  wir  bekanntlich 
eine  lappige,  unformliche  Hypertrophie  der  Haut  der  Nase 
und  der  angrenzenden  Wangenhaut.  Ich  gehe  auf  dieselbe 
nicht  ausfuhrlich  ein,  da  ich  sie  erst  vor  kurzer  Zeit  in  einer 
besonderen  Arbeit  behandelt  habe. 1  Hier  will  ich  nur  daran 
erinnern,  dass,  wie  F.  Hebra  zuerst  bemerkte,  nur  Manner 
vom  Rhinophym  befallen  werden  und  diese  erst  nach  dem 
4osten  Lebensjahre.  Dieser  Umstand  hangt  damit  zusammen 
dass  nur  bei  Personen  mannlichen  Geschlechts  schon  physi- 
ologisch  eine  Hypertrophie  der  Talgdriisen  in  hoherem  Alter 
vorkommt,  die  eine  gelbliche,  gedunsene,  fettige,  mit  erweiter- 
ten  Ausfiihrungsgangen  der  Talgdriisen  besetzte  und  von 

1  Unna,  ("Rhinophym.")     Deutsche  Med.-Zeitung,  1904,  No.  25. 


DERMATOLOGICAL  CONGRESS  109 

varikosen  Venen  durchzogene  Nasenhaut  zur  Folge  hat. 
Leiden  dieselben  Individuen  ausserdem  noch  an  Rosacea,  so 
entwickelt  sich  im  Laufe  der  Jahre  das  monstrose  Bild  der 
"Pfundnase"  (des  Rhinophyms).  Hebra  wurde  wahrschein- 
lich  durch  diesen  Ausgang  in  Rhinophym  in  seiner  Ansicht 
bestarkt,  dass  die  Rosacea  von  Anfang  an  eine  Hypertrophie 
der  Haut  sei,  zuerst  der  Gefasse,  spater  der  Gesamthaut, 
wahrend  die  Akne  zu  den  Entzundungen  der  Haut  gehore. 
Ich  kann  diese  Ansicht  nicht  teilen.  Ich  trenne  die  Akne  noch 
viel  entschiedener  von  der  Rosacea  als  F.  Hebra,  aber  ich 
betrachte  die  letztere  doch  ebenfalls  als  eine  Entziindung 
der  Haut  und  zwar  als  eine  besondere,  durch  Gefasserweite- 
rung  ausgezeichnete  Form  des  seborrhoischen  Ekzems.  Das 
Rhinophym,  eine  zu  den  Granulomen  gehorige,  durch  ein 
prachtiges  Plasmom  gekennzeichnete,  entziindliche  Geschwulst 
1st  ein  atypischer,  nur  auf  besonders  vorbereitetem  Boden 
entstehender  Ausgang  der  Rosacea;  das  ergibt  sich  schon 
allein  aus  dem  Umstande,  dass  es  nie  bei  Frauen  vorkommt. 

Noch  in  einem  anderen  Punkte,  der  klinisch  von  nicht 
geringer  Bedeutung  ist,  muss  ich  F.  Hebra  widersprechen. 
Fur  ihn  ist  die  Rosacea  eine  Erkrankung  entweder  der  Pu- 
bertat  oder  des  Klimakteriums,  wie  er  denn  mit  besonderer 
Vorliebe  die  Beziehungen  derselben  zu  dem  Genitalsystem 
der  Frauen  erortert.  Schon  Hardy  hat  mit  Recht  dem- 
gegeniiber  betont,  dass  die  Rosacea  nicht  erst  mit  der  Meno- 
pause, sondern  gewohnlich  viel  fruher  auftritt.  Die  ersten 
Anfange  der  Rosacea  beobachtet  man  vom  25ten  Jahre 
aufwarts,  selten  fruher,  jedoch  meistens  etwas  spater, 
zwischen  dem  3osten  und  4osten  Jahre.  Wenn  das  Klimak- 
terium  iiberhaupt  einen  bestimmenden  Einfluss  besitzt,  so 
mochte  ich  es  am  ehesten  noch  fur  jene  Falle  vermuten,  wo 
bei  alteren  Damen  hartnakig  recidivierende,  knotchen- 
formige  Papeln  nur  am  Mund  und  Kinn  vorhanden  sind.  Auch 
durch  diese  Zeitbestimmungen  tritt  die  Rosacea  in  den 
schroffsten  Gegensatz  zur  Akne,  welche  den  Zeitraum  vom 
1 5 ten1  bis  zum  25sten  Jahre  beherrscht  und  in  alien  nicht 
allzu  schweren  Fallen  dann  von  selbst  vergeht.  Wenn  die 
Zeit  der  Akne  voniber  ist,  fangt  die  der  Rosacea  erst  an. 

1  Bei  Madchen  schon  vom  i3ten  Jahre  an. 


no  SIXTH  INTERNATIONAL 

Nur  selten  leiden  dieselben  Personen  an  beiden  Affektionen 
zugleich.  Wenn  dieses  aber  einmal  der  Fall  1st — namlich 
in  der  Mitte  der  zwanziger  Jahre — nur  dann  hat  man  Gelegen- 
heit,  beide  Diagnosen  Rosacea  und  Akne  am  selben  Patienten 
zu  machen;  man  sieht  noch  einzelne,  wenige  Komedonen 
und  Aknepusteln  neben  den  Anfangssymptomen  der  Rosacea. 
Erstere  schwinden  im  selben  Masse,  wie  die  letzteren  sich 
entwickeln. 

Zu  dieser  Reihe  der  Rosacea  selbst  angehorender  Symp- 
tome  treten  nun  in  den  meisten  Fallen  noch  gewisse  ander- 
weitige  Merkmale,  die  von  ebenso  grossem  diagnostischen 
wie  therapeutischen  Interesse  sind  und  welche  meine  These 
beweisen,  dass  die  Rosacea  nur  ein  Glied  in  der  Kette  der 
Erscheinungen  des  seborrhoischen  Ekzems  darstellt.  Diese 
Symptome  bestehen  entweder  gleichzeitig  mit  der  Rosacea 
oder  sie  sind  nur  auf  anamnestischem  Wege  festzustellen. 
Zu  den  ersteren  rechne  ich  vor  allem  die  Blepharitis  ciliaris, 
das  Ekzema  seborrhoicum  papulatum  des  Gesichtes  und 
Halses  und  des  ubrigen  Korpers  und  die  seborrhoische 
Alopecie.  Die  Blepharitis  ciliaris  begleitet  die  Rosacea  sehr 
haufig  und  geht  ihr,  da  sie  meistens  schon  in  der  Kindheit 
besteht,  gewohnlich  voran.  Sie  ist  dann  oft  der  letzte 
bleibende  Rest  eines  in  fruhestem  Kindesalter  iiberstandenen 
Kopf-  und  Gesichtsekzems  und  bildet  selbst  wieder  eine 
ekzematose  Etappe,  die  zur  Rosacea  im  mittleren  Lebens- 
alter  hinuberleitet.  Die  Patienten  sind  dann  meistens  so 
an  ihr  Leiden  und  die  sich  daran  anschliessenden  Conjunctival- 
katarrhe  gewohnt,  dass,  wenn  man  sie  auf  den  Zusammenhang 
mit  der  Rosacea  aufmerksam  macht  und  den  Wunsch  aus- 
spricht,  gleichzeitig  das  Ekzem  der  Augenlidrander — denn 
das  ist  die  Blepharitis  ciliaris — zu  heilen,  sie  ausweichend 
bemerken,  das  tue  nicht  notig,  dafur  ware  bereits  alles 
ohne  radikalen  Erfolg  versucht.  Wenn  durch  den  Reiz  der 
Blepharitis  und  Conjunctivitis  permanent  eine  starke  Thran- 
ensekretion  erzeugt  wird,  so  gesellt  sich  zu  der  Combination  von 
Blepharitis  und  Rosacea  noch  eine  Rhinitis  und  unter  Um- 
standen  ein  rhagadiformes  und  krustoses  Ekzem  des  Nasen- 
einganges  und  bei  Mannern  eventuell  noch  ein  subnasales 
Ekzema  pilare,  eine  sogenannte  subnasale  Sykosis.  Dieses 


DERMATOLOGICAL  CONGRESS  m 

1st  der  wahre  und  nach  meiner  Ueberzeugung  einzige  Zu- 
sammenhang  der  Rosacea  mit  Nasenleiden;  es  ist  die  fol- 
gerechte  Sequenz  einer  Blepharitis,  Conjunctivitis  und  Rhinitis 
ekzematosen  Ursprungs.  Dagegen  habe  ich  mich  von  dem 
Zusammenhang  anderer  Affektionen  der  Nasenschleimhaut 
mit  der  Rosacea,  wie  er  von  verschiedenen  Autoren  (Seiler, 
Sticker,  Bergh,  Brocq)  angenommen  wird,  nicht  tiberzeugen 
konnen  und  halte  in  keinem  Falle  die  Rosacea  fur  die  Folge 
solcher  Nasenleiden.  Ein  nicht  geringer  Teil  meiner  Rosa- 
cea Patienten  der  letzten  Jahre  war  ohne  jeden  Erfolg  vor- 
her  rhinologisch  behandelt  worden,  wahrend  die  antisebor- 
rhoische  Therapie  sofort  Heilung  brachte. 

Seltener  als  die  Blepharitis,  aber  doch  haufiger  als  man 
im  allgemeinen  annimmt,  finden  wir  die  Komplikation  der 
Rosacea  mit  einem  rotschuppigen  Ausschlag,  der  in  evidenter 
Weise  von  einem  schuppigen  oder  fettig-krustosen  Ekzem 
des  behaarten  Kopfes  seinen  Ausgang  nimmt  und  von  hier 
aus  gewohnlich  einerseits  den  Nacken  befallt  und  in  der 
Mittellinie  des  Ruckens  herabsteigt,  andererseits  die  Stirn, 
die  Seitenteile  des  Gesichtes  und  den  Hals  einnimmt  und  von 
hier  auf  die  mittleren  Teile  der  Brusthaut  ubergeht.  Es 
ist  dies  ein  typisches  Ekzema  seborrhoicum  papulatum.  Wo 
dasselbe  an  die  Rosacea  im  Bereich  des  Mittelgesichtes  an- 
grenzt,  konstatiert  man  einen  so  allmahlichen  Uebergang 
in  die  rotschuppigen  Flecke  der  Rosacea,  dass  man  zunachst 
an  der  Diagnose  Rosacea  uberhaupt  irre  wird.  Erst  die 
genauere  Betrachtung  der  letzteren  und  die  Anamnese,  welche 
den  vorherigen  Bestand  der  Rosacea  ergibt,  zeigt  uns,  dass 
der  Fall  als  der  akute  Ausbruch  eines  chronischen,  sebor- 
rhoischen  Ekzems  zu  deuten  ist,  dessen  Manifestationen  ausser 
in  latenten  Herden  des  behaarten  Kopfes  in  der  Rosacea 
bereits  seit  langer  Zeit  bestanden. 

Noch  seltener,  aber  den  ekzematosen  Ursprung  der 
Rosacea  vielleicht  noch  eindringlicher  vorfuhrend,  ist  die 
Komplikation  eines  nassenden,  krustosen  Ekzems  der  Seiten- 
teile des  Gesichtes  und  des  Halses  mit  der  Rosacea  des  Mittel- 
gesichtes— wenigstens  fur  die  Anhanger  der  alteren  Schule, 
welche  fur  die  Diagnose  Ekzem:  Blaschen  und  Nassen 
verlangen.  Auch  hier  gehen  die  nassenden  Partien,  welche 


ii2  SIXTH  INTERNATIONAL 

meistens  die  Ohren  umgeben,  ganz  allmahlich  und  unmerk- 
lich  uber  in  die  rotschuppigen  Elemente  der  Rosacea,  und 
im  ubrigen  ist  der  gesamte  Verlauf,  die  Praexistenz  alter 
seborrhoischer  Herde  des  behaarten  Kopfes  einerseits,  der 
Rosacea  anderseits  und  das  akute  Hinzutreten  der  manifesten, 
ekzematosen  Proruptionen,  genau  derselbe  wie  im  Falle  des 
Ekzema  seborrhoicum  papulatum.  An  solche  Falle  dachte 
Besnier  wohl,  als  er  bei  Besprechung  der  "Acne  rosacee" 
betonte,  dass  Falle  vorkamen,  wo  es  schwer  zu  entscheiden 
ware,  ob  es  sich  um  ein  "ecze"ma  acneique"  oder  eine  "acne 
ecze'matique  "  handle. 

Eine  sehr  haufige  und  schon  von  anderen  Autoren  (I. 
Neumann)  hervorgehobene  Komplikation  ist  die  mit  sebor- 
rhoischer Alopecie.  Aeltere  Herren  mit  Rosacea  pflegen  in  der 
iibergrossen  Mehrzahl  der  Falle  eine  Glatze  zu  haben  und 
wissen  meistens  auch  sehr  wohl,  dass  diese  selten  von  rot- 
schuppigen Flecken  frei  ist.  Wie  schon  oben  bemerkt, 
setzt  sich  haufig  die  Rosacea  als  breiter  roter  Streifen 
auf  den  kahlen  Scheitel  fort,  was  bei  der  friiher  angenom- 
menen  reflektorisch-vasomotorischen  Aetiologie  der  Rosacea 
unbegreiflich  war,  dagegen  bei  der  gemeinschaftlichen  sebor- 
rhoischen  Ursache  der  Alopecie  und  Rosacea  sehr  verstand- 
lich  ist.  Die  seborrhoische  Alopecie  kann  aber  auch  die 
Rosacea  komplizieren,  ohne  grade  zu  volliger  Kahlheit 
zu  fuhren.  Dieses  ist  besonders  bei  Frauen  der  Fall.  Ein 
starkerer  Haarausfall  kompliciert  in  der  Tat  viele  Falle 
von  Rosacea  der  Frauen,  und  es  ist  therapeutisch  von  Wich- 
tigkeit,  in  jedem  Falle  danach  und  nach  sonstigen  seborrhoi- 
schen  Symptomen  der  Kopfhaut  zu  forschen. 

Ich  kann  die  hiermit  gegebene  Darstellung  der  klinischen 
Erscheinungen  der  Rosacea  nicht  verlassen,  ohne  noch  zweier 
Affektionen  zu  gedenken,  welche  mit  der  seborrhoischen 
Rosacea  verwechselt  werden  konnen  und  es  in  der  Tat  hin  und 
wieder  werden.  Dieses  sind:  der  Frost  der  Nase  und  das 
Ulerythema  centrifugum  (Lupus  erythematosus). 

Diese  Rotung  der  Nase  durch  Frost  (Perniosis)  ist  eine 
sehr  seltene  Affektion  im  Vergleich  mit  der  seborrhoischen 
Rosacea,  wenigstens  in  meinem  Beobachtungskreise.  Sie 
wird  in  den  nordlichen  Gegenden  Europas  wohl  haufiger 


DERMATOLOGICAL  CONGRESS  113 

und  in  ausgedehnterer  Form  vorkommen;  wenigstens  habe 
ich  erst  einmal  bei  einer  Schwedin  und  einmal  bei  einer 
Russin  die  Affektion  sich  auf  die  Wangen  ausdehnen  sehen. 
Sie  befallt  mit  besonderer  Vorliebe  das  weibliche  Geschlecht 
und  stellt  sich  meistens  bereits  in  jugendlicherem  Alter  ein 
als  die  Rosacea,  die  das  mittlere  Lebensalter  bevorzugt.  Das 
Aussehen  des  Frostes  der  Nase  ist  von  vornherein  ein  viel 
gleichmassigeres  als  das  der  Rosacea  und  unterliegt  auch 
keinem  Wechsel  in  der  Zeit.  Die  Rote  setzt  sich  nicht  aus 
getrennten  Flecken  zusammen,  sondern  befallt,  von  der 
Nasenspitze  anfangend,  einen  mehr  oder  minder  grossen  Teil 
der  Nase  mit  gleichformiger  Rote.  Haufig  ist  nur  die 
Nasenspitze  allein  ergriffen,  ein  Zustand,  der  von  einigen 
Autoren  mit  Unrecht  als  gewohnlicher  Beginn  der  Rosacea 
hingestellt  ist.  Die  Grenze  der  Rote  ist  scharf  abgeschnitten 
und  geht  nicht,  wie  bei  der  Rosacea,  verwaschen  in  die  Umge- 
bung  liber;  auch  zeigt  diese  keine  seborrhoischen  Symptome, 
keine  Vergilbung,  keine  schuppigen  Flecke;  die  von  Frost 
befallene  Hautpartie  ist  gewohnlich  von  einem  reinen  und 
zarten  Teint  der  iibrigen  Gesichtshaut  umgeben.  Dagegen 
ergibt  die  weitere  Inspektion  in  den  meisten  Fallen  an  den 
anderen  Pradilektionsorten  (Finger,  Zehen,  Ohren)  die  be- 
kannten  Erscheinungen  des  Frostes  in  mehr  oder  minder 
starker  Auspragung;  nur  selten  befallt  der  Frost  die  Nase 
allein.  Die  Farbe  der  geroteten  Partie  ist  auch  nicht  dieselbe 
wie  bei  der  frisch  gelbroten  Rosacea,  sie  ist  blaulichrot,  bei 
einwirkender  Kalte  sogar  blaurot;  wie  immer,  wird  auch 
hier  die  blaue  Nuance  durch  Kontraktion  der  oberflachlichen 
Kapillaren  hervorgebracht,  indem  die  tiefliegenden,  blut- 
uberfullten  Kapillaren  dann  durch  eine  weissliche  Schicht 
hindurchschimmern.  Die  Oberflache  ist  glatt,  oft  sogar 
glanzend  durch  eine  leichte  Anschwellung  der  Cutis,  nicht 
durch  fettiges  Sekret,  wahrend  sie  bei  der  Rosacea  matt, 
sogar  schuppig,  oder  auch  fettglanzend  erscheint.  Die 
Ektasien  der  groberen  Venen,  welche  bei  der  Rosacea  eine 
solche  Rolle  spielen,  fehlen  beim  Froste  oder  kommen  inner- 
halb  der  Kapillarektasie  nicht  zur  Geltung.  Fraglos  wirken 
alle  gefasslahmenden  Einflusse  innerer  oder  ausserer  Art, 
welche  die  Rosacea  verstarken,  auch  auf  den  Frost  der  Nase 

VOL.  I. — 8 


ii4  SIXTH  INTERNATIONAL 

verschlimmernd  ein ;  unter  diesen  nimmt  aber  die  Kalte  den 
weitaus  bedeutendensten  Rang  ein,  sie  ist  gradezu  der  spezi- 
fische  Reiz  fiir  diese  Art  der  Gefassparese,  wahrend  z.  B. 
mechanische  Reibung,  die  unter  alien  Umstanden  die  Rosacea 
verschlimmert,  beim  Frost  bis  zu  einem  gewissen  Grade 
wohltatig  wirken  kann.  Wenn  wir  den  Frost  der  Nase  mit 
den  bekannteren  Lokalisationen  des  Frostes  an  Handen  und 
Fiissen  vergleichen,  so  entspricht  derselbe  stets  nur  dem 
schwacheren  Grade  allgemeiner,  gleichmassiger  Stauung; 
Frostbeulen,  d.  h.  umschriebene,  heftig  juckende  Oedeme  um 
eine  kleine  centrale,  diapedetische  Blutung,  sind  mir  bisher 
an  der  Nase  nicht  begegnet. 

Ueberblickt  man  die  samtlichen  Symptome  und  den 
ganzen  Verlauf  des  Frostes  einerseits  und  der  Rosacea  anderer- 
seits,  so  erscheinen  sie  als  ganz  verschiedene  Erkrankungen 
der  Haut,  die  nur  durch  die  Lokalisation  und  den  labilen 
Gefasstonus  der  Gesichtshaut  in  geringem  Grade  verahn- 
licht  werden.  Da  das  angioneurotische  Element  beim  Frost 
in  den  Vordergrund  tritt,  hat  man  diesen — und  ich  selbst 
friiher  auch — als  angioneurotische  Rosacea  von  der  sebor- 
rhoischen  zu  scheiden  gesucht ;  aber  ich  halte  es  fiir  viel  besser 
und  die  Verhaltnisse  klarender,  wenn  man  den  einmal 
eingefiihrten,  guten  Namen:  Frost,  Perniosis,  fiir  diese  Form 
des  Erythems  reserviert  und  Rosacea  nur  die  seborrhoische, 
durch  Angiektasie  ausgezeichnete  Entziindungsform  des 
Gesichtes  nennt. 

Die  Differentialdiagnose  der  (seborrhoischen)  Rosacea 
vom  Ulerythema  centrifugum  (sog.  Lupus  erythematosus) 
wird  von  manchen  Autoren,  z.  B.  Lesser,  fiir  eine  stets  leichte 
gehalten.  In  der  Tat  ist  es  auch  hier  eigentlich  nur  die 
Lokalisation  auf  Nase  und  Wangen  (in  Schmetterlingsform) 
und  die  Entzundungsrote,  welche  beide  sonst  grundver- 
schiedene  Affektionen  ahnlich  macht;  immerhin  kommen 
bei  schwacher  Auspragung  der  Symptome  des  Ulerythems 
oder  starkerer  der  Rosacea  Verwechslungen  tatsachlich  vor, 
sodass  ich  eine  kurze  Zusammenfassung  der  hauptsach- 
lichsten  Differenzpunkte  nicht  fiir  iiberfliissig  erachte.  Was 
zunachst  die  Lokalisation  betrifft,  so  ergreift  das  Ulery- 
them  ausser  dem  Gesicht  haufig  auch  den  behaarten  Kopf, 


DERMATOLOGICAL  CONGRESS  115 

die  Ohren  und  die  Hande  und  zwar  in  einer  Form,  die  den 
Gedanken  an  Rosacea  ausschliesst.  Der  rasche  Wandel  der 
Rote  unter  dem  Einflusse  innerer  und  ausserer  Reize,  die 
charakteristischen  Venenektasien,  die  Papeln  und  Pusteln  und 
die  begleitenden  seborrhoischen  Phanomene  welche  die  Ro- 
sacea charakterisieren,  fehlen  dem  Ulerythem.  Anderseits 
findet  sich  bei  letzterem  ein  erhabener,  serpiginos  fortschreiten- 
der  und  dabei  die  angioparetische  Region  des  Mittelgesichtes 
auch  ohne  weiteres  uberschreitender  Rand,  wahrend  die 
centrale  Partie  nach  langerem  Bestande  stets  atrophisch, 
narbenahnlich  zuriickbleibt,  in  anderen  Fallen  durch  ein 
stabiles  Oedem  ausgezeichnet  wird.  Diese  Symptome  fehlen 
der  Rosacea  ganzlich.  Eine  schuppige  Beschaffenheit,  die 
ja  das  Ulerythem  ebenfalls  charakterisiert,  fehlt  der  Rosacea 
nicht  vollkommen,  doch  sind  die  Schuppchen  hier  unregel- 
massig  und  fettig,  dort  fast  regelmassig  vorhanden,  sehr 
trocken  und  an  der  Unterseite  mit  hornigen  Fortsatzen 
versehen.  Uebrigens  liegt  eine  Verwechselung  beider  Affek- 
tionen  nur  dann  im  Bereiche  der  Moglichkeit,  wenn  eine 
Rosacea  als  einzelne,  kontinuierliche  Flache,  nicht  wenn 
sie,  wie  gewohnlich,  in  vielen  zerstreuten  Flecken  auftritt. 

In  dieser  klinischen  Schilderung  sind  implicite  schon 
manche  Punkte  zur  Sprache  gekommen,  welche  fur  die 
Aetiologie  von  entscheidender  Bedeutung  sind.  Wenn  die 
Rosacea  eine  nur  durch  besondere  lokale  Verhaltnisse  eigen- 
tumlich  veranderte  Teilerscheinung  des  seborrhoischen  Ent- 
zundungsprocesses  der  Oberhaut  ist,  so  teilt  sie  die  Aetiologie 
des  letzteren,  und  wenn,  wie  ich  es  seit  langer  Zeit  und — 
wie  ich  glaube — mit  guten  Griinden  vertrete,  das  sebor- 
rhoische  Ekzem  eine  parasitare  Oberhautentziindung  ist, 
so  sind  es  die  parasitaren  Keime  dieser,  welche  auch  die 
Rosacea  verursachen.  Diese  bilden  also  die  wesentliche,  die 
permanente  Ursache  der  Rosacea.  Mit  diesem  Satze  verweise 
ich  zugleich  das  Heer  der  seit  einem  Jahrhundert  mit  mehr 
oder  weniger  Sicherheit  angenommenen  Ursachen,  soweit  sie 
sich  uberhaupt  als  haltbar  erweisen,  in  die  Klasse  der  Hulfs- 
ursachen  oder,  noch  genauer  gesagt,  der  accidentellen  period- 
ischen  Ursachen.  Wahrend  die  Permanenz  der  wesentlichen 
Ursache,  des  seborrhoischen  Keimes,  die  jahrelange  Dauer 


n6  SIXTH  INTERNATIONAL 

der  Rosacea  begrundet,  begriindet  die  Periodicitat  der 
accidentellen  Ursachen  die  in  Schuben  erfolgende  Verschlim- 
merung  und  Ausbreitung  derselben.  Die  periodischen  Hiilfs- 
ursachen  fur  sich  allein  erzeugen  nie  das  klinische  Bild  der 
Rosacea,  wohl  aber  genugt  dazu  bei  der  eigentumlichen 
Beschaffenheit  der  Gesichtshaut  der  Keim  des  seborrhoischen 
Ekzems,  nur  bleibt  das  Krankheitsbild  in  der  Entwicklung 
zuriick,  wenn  nicht  die  periodischen  Htilfsursachen  sein 
Aufbliihen  befordern. 

Diese  letzteren  zerfallen  wieder  in  die  beiden  natiirlichen 
Gruppen  der  dusseren  oder  lokalen  Reize  und  der  inner  en, 
entfernten,  auf  dem  Nervenwege  zugefuhrten  Reize. 

Unter  den  lokalen  Reizen  treten  besonders  zwei  als  die 
wichtigsten  von  alien  accidentellen  Ursachen  hervor,  die 
fast  in  keinem  einzigen  Falle  ohne  Schuld  an  der  Ausbreitung 
der  Rosacea  sind:  die  Reibung  und  die  Kdlte.  Der  Einfluss 
der  Reibung  der  Gesichtshaut  mit  dem  Handtuch  und  Tasch- 
entuch  wird  gewohnlich  unterschatzt,  obwohl  jeder  weiss, 
wie  leicht  ein  blasses  Gesicht  durch  Reiben  gerotet  werden 
kann.  Der  Einfluss  der  Kalte  ist  schon  seit  langer  Zeit  als 
ein  wichtiger  Faktor  beim  Zustandekommen  der  Rosacea 
anerkannt,  wenn  auch  falschlich  als  zu  reichende  Ursache1 
angesehen,  wahrend  sie  nur  eine  der  wichtigsten  accidentellen 
Ursachen  ist.  Starker  noch  als  die  Kalte  allein  wirkt  eine 
voriibergehende  starke  Abkiihlung  mit  nachfolgendem  Warme- 
einfluss  und  am  starksten,  wenn  ausser  der  Kalte  gleich- 
zeitig  noch  ein  mechanischer  Effekt  auf  die  Gesichtshaut 
ausgeiibt  wird,  so  z.  B.  der  Eintritt  in  ein  stark  geheiztes 
Zimmer  nach  einem  Marsch  oder  Ritt  gegen  eisigen  Wind. 
Als  dritter  unter  den  lokalen  Reizen  ist  neben  der  Reibung 
und  der  Kalte  der  chemische  Reiz  zu  nennen,  welcher  meisten- 
teils  in  der  Gestalt  von  unpassenden  Medikamenten  auf  die 
Rosacea  verschlimmernd  einwirkt.  Schon  Willan  wusste, 
dass  seine  "Acne  Rosacea"  im  Gegensatz  zu  seinen  anderen 
Akneformen  "milde  astringierend "  behandelt  und  jeder 
Reiz  vermieden  werden  musste.  Besnier  und  Doyon  heben 
ebenfalls  die  ' '  Intoleranz "  der  Affektion  hervor  und  raten 
zur  Anwendung  von  "Anodyna, "  und  aus  demselben  Grunde 

1  Das  ist  sie  ftir  den  Frost  der  Nase. 


DERMATOLOGICAL  CONGRESS  117 

1st  die  Rosacea  fur  viele  praktische  Aerzte  em  Noli  me 
tangere.  Dieselbe  Bedeutung  hat  das  Wort  von  F.  Hebra,  dass 
auch  bei  der  von  ihm  empfohlenen  Behandlung  gewohnlich 
"zuerst  eine  Verschlimmerung "  eintrete.  Wir  werden  sehen, 
dass  bei  richtiger  Behandlung  die  Rosacea  anstandslos  heilt, 
ohne  dass  erst  ein  "  Stadium  der  Reizungdurch  Medikamente" 
zu  iiberwinden  ist;  wir  werden  uns  aber  bei  der  Behandlung 
der  Rosacea  stets  dieser  so  sehr  begreiflichen  besonderen 
"  Reizbarkeit "  der  schon  unter  einem  permanenten  Reiz 
leidenden  Gesichtshaut  erinnern  mussen. 

Die  inneren,  auf  reflektorischem  Wege  der  Gesichtshaut 
zugefuhrten  Reize  lassen  sich  alle  kurzerhand  unter  dem 
Begriffe  der  Blutwallungen  zum  Kopfe  zusammenfassen, 
seien  sie  als  mehr  zufallige  und  seltnere  Ereignisse  durch  die 
verschiedensten  Umstande  hervorgerufen  oder  als  habituelle 
Wallungen  Folgen  bestimmter  Nerven-,  Gefass-  oder  Herz- 
affektionen.  Es  sind  unter  der  langen  Ungewissheit  iiber 
die  wahre  Ursache  der  Rosacea  sehr  viele  Affektionen  innerer 
Organe,  man  kann  sagen,  der  Reihe  nach  so  ziemlich  alle  als 
wirksam  beschuldigt  worden.  Schon  Hardy  hat  die  seit  Biett 
und  Cazenave  in  Frankreich  angeschuldigten  Magen-,  Leber- 
und  Uterusaffektionen  von  diesem  Verdachte  freigesprochen 
und  auch  die  von  F.  Hebra  mit  grosser  Ausfiihrlichkeit  be- 
handelten  Menstruationsanomalien  nicht  gelten  lassen — und 
sehr  mit  Recht.  Alle  diese  Komplikationen  beruhen  auf 
einem  zufalligen  Zusammentreffen  und  konnen  eine  Rosacea 
nur  dann  verschlimmern  und  unterhalten,  wenn  sie  mit 
Blutwallungen  kompliziert  sind,  welche  diese  Wirkung  aber 
auch  ganz  fur  sich  ausiiben.  Viel  eher  sind  diejenigen 
Zustdnde  und  Gewohnheiten  verantwortlich  zu  machen, 
welche  direkt  die  Neigung  zu  Blutwallungen  befordern,  so 
die  habituelle  Verstopfung,  kalte  Fusse  und  sitzende  Lebensweise 
oder,  wie  Hardy  treffend  bemerkt:  die  Beschaftigung  mit 
der  Feder  und  der  Nahnadel.  Vieles,  was  Menstruations- 
anomalien und  Magenleiden  zugeschrieben  wurde,  wird  in 
diesem  Zusammenhange  erst  verstandlich.  Inwiefern  Ka- 
tarrhe  der  Nasenschleimhaut  mit  der  Rosacea  atiologisch 
in  Zusammenhang  stehen  konnen  und  dass  fur  gewohnlich 
eine  Rhinitis  nicht  als  Ursache  in  Frage  kommt,  ist  bereits 


n8  SIXTH  INTERNATIONAL 

oben  erwahnt.  Hier  miissen  wir  aber  nicht  vergessen  zu 
betonen,  dass  die  Reibung  des  bei  alien  Affektionen  der 
Nasenschleimhaut  viel  gebrauchten  Taschentuches  sehr  zur 
Verschlimmerung  einer  bestehenden  Rosacea  beitragt,  ein 
ausserer  Reiz,  der  langdauernde  Parese  der  Hautgefasse 
zur  Folge  hat  und  nur  zu  gewohnlich  ist,  um  beachtet  zu 
werden. 

Wir  kommen  hiermit  zu  den  letzten  und — wenn  man  der 
Literatur  unbedingten  Glauben  schenken  konnte — wichtigsten 
unter  den  accidentellen  Ursachen,  zu  der  Blutwallung  durch 
Ingesta  und  ganz  speziell  durch  AlkohoL  Dass  die  rote  Nase 
das  heitere  und  natiirliche  Abzeichen  der  Schlemmer  und 
besonders  der  Trinker  sei,  ist  ein  uralter  Volksglaube,  dem 
sich  auch  die  Aerzte  aller  Zeiten  nicht  ganz  entziehen  konnten. 

Freilich  wussten  es  die  Aerzte  besser,  und  seit  Devergie 
haben  die  meisten  besonnenen  Dermatologen  darauf  auf- 
merksam  gemacht,  dass  sehr  oft  die  massigsten  Leute  mit 
ausgesprochener  Rosacea  umherwandeln.  In  England  weist 
man  darauf  hin,  dass  hochwurdige,  iiber  jedem  Verdachte 
des  Poculierens  erhabene  Geistliche  an  diesem  Uebel  leiden, 
ein  Argument,  dem  bei  uns,  im  Vaterlande  Grutzners,  aller- 
dings  nicht  eine  ebenso  hohe  Beweiskraft  zukommen  wiirde. 
Aber  muss  es  nicht  Jeden,  der  nur  einigermassen  beobachtet, 
stutzig  machen,  dass  so  viel  mehr  Frauen  an  Rosacea  leiden 
als  Manner,  was  doch  umgekehrt  sein  musste,  wenn  jene 
Lebensgewohnheiten  einen  so  grossen  Einfluss  wirklich  be- 
sassen?  Im  Grunde  weiss  jeder  erfahrene  Dermatologe,  dass 
hochste  Massigkeit,  ja  absolute  Abstinenz  nicht  im  mindesten 
vor  Rosacea  schutzt;  aber  seit  Rayer  die  Couperose  als  ein 
viel  schlimmeres  Uebel  hinstellte  als  die  Akne  und  Bazin  von 
der  "  unheilbaren  Trinkernase"  sprach,  sind  die  Dermatologen 
im  allgemeinen  doch  nur  zu  sehr  geneigt,  mangelhafte  Heiler- 
folge  bei  dieser  Krankheit  den  Patienten  in  die  Schuhe  zu 
schieben.  F.  Hebra  halt  die  Rosacea  oft  fur  unheilbar, 
"da  iible  Gewohnheiten  nicht  gelassen  werden,"  und  wenn 
Lesser  sagt,  dass  eine  atiologische  Behandlung  oft  unmoglich 
sei,  so  hat  er  in  erster  Linie  auch  wohl  den  bosen  Alkohol  im 
Auge. 

Tatsachlich    liegt    die    Sache    so,    dass    kein    erfahrener 


DERMATOLOGICAL  CONGRESS  119 

Dermatologe  ernstlich  den  gewohnheitsgemassen  Alkoholgenuss 
als  zureichenden  Grund  fur  das  Entstehen  der  Rosacea  an- 
nimmt.  Ich  aber  gehe  welter  und  behaupte  nach  langjahriger 
Erfahrung,  dass  dieses  Moment  nicht  bloss  keine  wahre 
Ursache  der  Rosacea  ist,  sondern  auch  nur  in  sehr  seltenen 
Ausnahmefallen  die  Rolle  einer  Hulfsursache  spielt.  Die 
Rosaceapatienten  gehoren  namlich  fast  stets  zu  den  massig- 
sten  Menschen  und  wenn  einmal  Gewohnheitstrinker,  was 
natiirlich  auch  vorkommt,  mit  Rosacea  behaftet  sind,  so 
lassen  sich  regelmassig  noch  andere  schadliche  Momente, 
wie  Kalte  und  Wind  bei  Kutschern,1  auffinden,  ohne  welche 
der  Alkohol  allein  nicht  diese  schadigende  Wirkung  entfaltet 
hatte. 

Hiermit  soil  natiirlich  nicht  geleugnet  werden,  dass  unter 
.  Umstanden  ein  Glas  Wein  schon  eine  plotzliche  Blutwallung 
zum  Kopfe  veranlasst  und  dass  reichliche  Mahlzeiten,  bei 
denen  viel  Wein  getrunken  wird,  langdauernde  Hyperamie 
der  Gesichtshaut  zur  Folge  haben  konnen,  die  fur  eine 
bestehende  Rosacea  verhangnisvoll  werden  mogen.  Aber 
das  ist  eben  das  Bemerkenswerte,  dass  die  Rosaceapatienten 
im  allgemeinen  jede  solche  Gefdssaufregung,  wie  sie  durch 
Alkohol  oder  ein  anderes  Genussmittel  (Kaffee,  starke  Ge- 
wiirze)  erzeugt  werden  kann,  dngstlich  vermeiden.  Sie 
kennen  die  Schadlichkeit  sehr  gut  und  wissen  nicht  nur, 
dass  sie  sofort  darunter  zu  leiden  haben,  sondern  furchten 
sich  noch  weit  mehr  vor  dem  unbegrimdeten,  aber  allver- 
breiteten  Vorurteil,  dass  ihr  ganzes  Leiden  vom  Trinken 
herruhre.  Von  der  Gesellschaft  in  eine  Art  humoristicher 
Acht  erklart,  haben  sie  gewohnlich  langst,  ehe  sie  den  Arzt 
aufsuchen,  sich  nolens  volens  zu  einem  massigen,  ja  ent- 
behrungsreichen  Leben,  zu  einer  freiwilligen  Abstinenz  erzogen. 
Mit  einem  Wort:  sie  sind  mdssig,  weil  sie  an  Rosacea  leiden. 
Der  Arzt  kommt  also,  wenn  er  den  Massigkeitsapostel  spielen 

1  Dass  grade  bei  Kutschern  und  besonders  Droschkenkutschern  sich 
relativ  viel  Prachtexemplare  von  Rosacea  und  Rhinophym  finden,  ist 
leicht  verstandlich.  Hier  losen  sich  die  accidentellen  schadigenden 
Ursachen  in  regelmassigem  Wechsel  ab.  Um  der  Kalte  und  dem  Wind 
zu  widerstehen,  geht  der  mit  Rosacea  behaftete  Kutscher  in  die  warme 
Kneipe;  dann  setzt  er  sich  wieder  der  Kalte  aus  u.  s.  f. ;  ein  richtiger  circulus 
vitiosus. 


120  SIXTH  INTERNATIONAL 

will,  mit  seinem  guten  Rat  zu  spat;  er  hat  daher  auch,  wenn 
er  erfolglos  ist,  nicht  die  gute  Ausrede,  dass  "bose  Gewohn- 
heiten  nicht  gelassen  werden.  " 

Die  klinische  und  atiologische  Auffassung  der  Rosacea, 
welcher  ich  im  bisherigen  Ausdruck  verliehen  habe,  fuhrt 
nun,  wie  sich  leicht  ergibt,  zu  einer  ganz  anderen  und  neuen 
Gestaltung  der  Prognose.  Aus  einer  fruher  ganz  schlechten, 
in  neueren  Zeiten  immer  noch  recht  zweifelhaften  ist  sie  dank 
der  veranderten  Anschauung  vom  Wesen  der  Rosacea  eine 
durchaus  gute  geworden.  Fruher  kampfte  man  gegen  ein 
Heer  von  entfernten,  unbekannten  Ursachen  ohne  Hoffnung 
auf  Erfolg,  ut  aliquit  fieri  videretur,  und  der  Volksmund 
erklarte  die  "Couperose"  fur  unheilbar.  In  neueren  Zeiten 
tat  man  ortlich  mehr;  alle  Hulfsmittel  der  kleinen  Chirurgie 
fuhrte  man  sogar  ins  Feld,  da  man  der  Wirkung  chemischer 
Mittel  bei  dieser  Affektion  wenig  Vertrauen  entgegenbrachte, 
und  uberall  lautete  das  letzte  Urteil:  die  Prognose  ist  un- 
sicher.  Selbst  ein  Meister  der  ortlichen  Behandlung  wie 
F.  Hebra  nimmt  seine  Zuflucht  zu  den  "bosen  Gewohn- 
heiten, "  um  Miserfolge  zu  erklaren.  Wir  konnen  aber 
jetzt  mit  Fug  und  Recht  sagen:  jede  Rosacea  ist  heilbar,  und 
zwar  auf  relativ  einfachem  Wege.  Dieses  gilt  auch  fur  die 
hochgradigsten  Falle;  um  vieles  mehr  aber  noch  fur  die 
leichteren  und  die  Anfange.  Diese  besser  als  bisher  zu 
beobachten  und  fruhzeitiger  als  bisher  einer  geeigneten 
Therapie  zu  unterwerfen,  ist  nun  die  Sache  der  praktischen 
Aerzte. 

Da  wir  wissen,  dass  alle  accidentellen  oder  Hulfsursachen 
doch  nur  durch  das  Medium  der  Blutwallung  zum  Kopfe 
auf  die  Rosacea  einwirken,  so  haben  wir  nicht  jenen,  sondern 
nur  dieser  alle  unsere  Aufmerksamkeit  zuzuwenden.  Wir 
beginnen  nicht  damit,  dem  Patienten  eine  bestimmte  Diat 
vorzuschreiben,  dieselbe  mag  fur  begleitende  Konstitutions- 
anomalien  noch  so  empfehlenswert  sein,  sondern  wir  haben 
zuerst  den  Patienten  zu  fragen,  ob  er  bemerkt  habe,  dass 
gewisse  Speisen  oder  Getranke  bei  ihm  sofort  eine  Blut- 
wallung nach  dem  Gesichte  zur  Folge  haben  und  welche. 
Wir  entgehen  dadurch  der  unangenehmen  Lage,  dem  Patienten 
autoritativ  etwas  zu  verbieten,  was  er  langst  schon  selbst 


DERMATOLOGICAL  CONGRESS  121 

vermieden  hat  und  der  ebensowenig  beneidenswerten,  ihm 
etwas  in  schablonenhafter  Weise  zu  untersagen,  was  gar 
keinen  Einfluss  auf  die  Parese  seiner  Hautgefasse  besitzt. 
Der  Patient  weiss  stets  besser  als  wir,  ob  bei  ihm  grade  eine 
heisse  Suppe  oder  ein  Glas  Rotwein  bei  Tische  oder  eine  Tasse 
Kaffee  nach  Tische  oder  ein  saurer  Salat  oder  Pfeffer  oder 
Ingwer  oder  eine  Kombination  dieser  Reizmittel  oder  kein 
einziges  derselben  den  Effekt  einer  sofortigen  Erschlaffung  der 
Hautarterien  im  Gesichte  besitzt.  Was  wir  tun  konnen  ist  nur, 
ihn  darin  zu  bestarken,  die  als  solche  fur  seinen  speziellen 
Fall  erfahrungsgemass  feststehenden  Reizmittel  zu  vermeiden 
und,  vielleicht  in  Zukunft  noch  mehr  als  bisher,  seine  Natur 
nach  dieser  Richtung  zu  studieren.  Es  kommen  bei  dieser 
Erorterung  die  merkwurdigsten  Bekenntnisse  zutage,  und  ich 
habe  mich  viel  ofter  veranlasst  gesehen,  die  von  anderen 
Aerzten  und  Laien  eingeschuchterten  Patienten  wieder  an 
ihre  fruhere  Lebensweise,  wenn  sie  ihnen  sonst  gut  bekam, 
j  a  selbst  an  Getranke  und  Gewiirze,  wieder  zu  gewohnen, 
da  sie  "  erfahrungsgemass  keine  Verschlimmerung  der  Haut- 
rote  bewirkten,"  als  die  armen  Dulder  noch  weiter  in  ihrem 
Lebensgenuss  zu  beeintrachtigen. 

Nach  dieser  einleitenden  Erorterung,  der,  wie  man  sieht, 
garnicht  die  fundamentale  Bedeutung  zukommt  wie  man  all- 
gemein  glaubt,  wendet  man  sich  direkt  zur  Beseitigung  der  in 
jedem  Falle  vorhandenen  wirklichen  Schadlichkeiten ;  es  sind 
die  besprochenen  zwei :  Reibung  und  Kalte ;  mit  diesen  nimmt 
man  es  aber  um  so  emster.  Alle  Reinigungen  und  Waschungen 
des  Gesichtes  sind  mit  schadlicher  Reibung  verbunden;  da 
sie  nicht  zu  umgehen  sind,  mussen  sie  womoglich  auf  eine 
beschrankt  und  auf  den  Abend  verlegt  werden,  damit  nicht 
weitere  Reizungen  hinzutreten.  Kaltes  Wasser  ist  der  abnorm 
blutreichen  und  daher  abnorm  warmen  Gesichtshaut 
angenehm,  aber  nicht  zutraglich,  da  regelmassig  nach  seiner 
Anwendung  eine  nachhaltige  reaktive  Blutwallung  folgt.  Es 
wird  daher  niemals  kaltes,  sondern  nur  warmes  Wasser  mit 
der  Gesichtshaut  in  Beruhrung  gebracht.  Diese  Ueberle- 
gungen  allein  leiten  schon  zu  einem  strikt  durchzufuhrenden, 
fur  alle  Rosaceapatienten  gleichmassig  forderlichen  Be- 
handlungsplan.  Der  Staub  des  Tages  wird  abends  vor  dem 


122  SIXTH  INTERNATIONAL 

Zubettegehen  mit  warmem  Wasser — und  eventuell  einer  sehr 
milden  Seife  —  leicht  abgespiilt  und  die  Haut  dann  nicht 
durch  Abreiben,  sondern  durch  leichtes  Betupfen  mit  weichen 
Tiichern  (alten  Handttichern,  alten  Taschentiichern)  ge- 
trochnet,  wobei  es  garnicht  schadet,  wenn  die  letzte  Feuch- 
tigkeit  der  spontanen  Verdunstung  iiberlassen  wird.  Es 
wird  sodann  eine  der  spater  zu  besprechenden,  spezifisch 
wirksamen  Fasten  oder  Salben  auf  die  erkrankte  Haut  auf- 
gestrichen  (nicht  eingerieben)  und  eine  Mullbinde  mit  so 
wenig  Touren  wie  moglich,  aber  geniigend  fest  so  um  das 
Gesicht  gelegt,  dass  sie  wenigstens  den  grossten  Teil  der 
Nacht  sitzen  bleibt.  Viele  Touren  oder  eine  dichtere  Binde 
wiirden  das  Gesicht  zu  warm  machen;  die  Binde  ist  notig 
nicht  nur  um  die  Beschmutzung  der  Kissen  und  das  Abwischen 
der  Salbe,  sondern  vor  allem  um  das  Reiben  der  Gesichtshaut 
auf  den  Kissen  zu  vermeiden,  was  bei  der  Rosacea  wie  bei 
jeder  Form  von  Gesichtsekzem  schadlich  ist.  Bei  der 
Morgentoilette  ganz  besonders  ist  das,  was  man  zu  vermeiden 
hat,  wichtiger  als  das  was  man  tut;  hier  wird  im  allge- 
meinen  am  meisten  gesiindigt.  Der  Laie  wascht,  reibt,  kiihlt 
und  setzt  sich  dann  den  Schadlichkeiten  des  Tages  aus, 
als  ob  alle  diese  Dinge  nicht  grade  die  besten  Mittel  waren 
um  jede  Rosacea  zu  verschlimmern.  Am  ratsamsten  ware 
es,  die  wahrend  der  Nacht  erzielte  Abblassung  dadurch  bei 
Tage  zu  erhalten,  dass  man  morgens  garments  tate  und  die 
Gesichtshaut  nicht  anruhrte,  hochstens  die  Salbenreste  durch 
sanftes  Ueberwischen  unsichtbar  machte.  Auch  ein  leichtes 
Ueberwischen  mit  einem  (hautfarbenen)  Puder  wiirde  nicht 
schaden.  Dazu  sind  aber  viele  Patienten  nicht  zu  bewegen; 
sie  wollen  morgens  eine  "  Erfrischung "  haben.  Man  muss 
ihnen  dann  nur  klar  machen,  dass  fiir  ihre  Haut  nie  die 
"  direkte  Erfrischung"  mit  kaltem  Wasser,  sondern  immer 
nur  die  "indirekte  Erfrischung"  durch  warmes  Wasser  passt, 
und  kann  ihnen  dann  erlauben,  die  Gesichtshaut  morgens 
mit  warmem  Wasser  mehrmals  leicht  zu  betupfen  und  die 
Feuchtigkeit  der  kiihlenden  Abdunstung  zu  iiberlassen  oder 
ohne  Reibung  abzuwischen. 1  Hierauf  folgt  dann  die  Tages- 
behandlung  mit  Puder  oder  Paste.  Wahrend  des  Tages  pflegt 

1  C'est    le    ton    qui    fait    la    musique.     Auch    F.    Hebra   braucht    eine 


DERMATOLOGICAL  CONGRESS  123 

der  Rosaceapatient  aber  noch  mehrmals  seinen  Teint  zu 
mishandeln,  je  nachdem  die  Sonne,  der  Staub,  der  Wind  oder 
die  Kalte  auf  denselben  eingewirkt  haben.  Im  Sommer,  wenn 
er  heisser  und  roter  als  andere  Menschen  nach  einem  Spazier- 
gange  sein  Haus  betritt,  ist  sein  erster  Gedanke :  Kaltes  Wasser 
zum  Waschen;  ebenso  auch  im  Winter,  wenn  er  nach  einem 
Aufenthalt  im  Freien  bei  starkem  Frost  in  sein  geheiztes  Zim- 
mer  kommt  und  die  bis  dahin  durch  die  Kalte  bewirkte 
Verengerung  der  Gefasse  explosionsartig  in  eine  hochgradige 
und  dauernde  Blutwallung  umschlagt.  Hier  ist  eine  gewisse 
Selbsterziehung  durchaus  notwendig;  die  "  Erfrischung" 
wird  nicht  im  Schlafzimmer  und  einer  Kanne  kalten 
Wassers,  sondern  in  der  Kiiche  in  einem  Topf  heissen  Wassers 
gefunden.  Man  nimmt  das  Wasser  so  heiss  wie  man  es  irgend 
ertragen  kann,  taucht  einen  Schwamm  oder  Flanellappen 
hinein  und  driickt  denselben  einige  Sekunden  auf  die  heisse 
Gesichtshaut,  entfernt  ihn  wieder,  damit  die  Hautflache 
sich  abkuhlen  kann,  benetzt  sie  wieder  mit  dem  heissen 
Wasser  und  so  einige  Male,  bis  das  Gefuhl  und  das  Aussehen 
im  Spiegel  anzeigt,  dass  die  Parese  wieder  dem  normalen 
Tonus  Platz  gemacht  hat.  Wenn  eine  Tagbehandlung  in- 
diziert  war,  folgt  dieselbe  darauf  sofort  in  Gestalt  einer  Puder- 
oder  Pastenapplikation.  Eine  solche  "heise  Abschreckung" 
— dieser  Name  hat  sich  fur  die  ganze  vasotherapeutische 
Procedur  eingeburgert — ist  fur  den  Rosaceapatienten  stets 
wohltatig  und  kann  im  Verlauf  eines  Tages  ofter  wiederholt 
werden,  so  besonders  nach  den  Mahlzeiten,  nach  anstrengenden 
Arbeiten,  Sport,  etc.  Speziell  ist  die  heisse  Abschreckung 
indiziert,  ehe  der  Patient  aus  dem  Winterfroste  in  die  warme 
Stube  tritt;  er  wird  finden,  dass  es  dann  nicht  zu  der  er- 
warteten  Blutwallung  kommt.  Manchem  werden  diese  Vor- 
schriften  zu  kleinlich  vorkommen,  sie  sind  aber  noch  nicht 
detailliert  genug  und  mussen  fur  jeden  Fall  unter  Beriick- 
sichtigung  seiner  Eigenheiten  noch  vervollstandigt  werden. 
Wer  so  versteht,  statt  der  vermeintlichen  Diatfehler  dem 
Patienten  seine  bisherigen  Sunden  in  der  Hautpflege  klar  zu 
machen  und  diese  abzustellen,  hat  schon  den  schwierigsten 

Schwefelsalbe  wie  ich,  aber  er  lasst  sie  "abends  energisch  einreiben" 
und  "morgens  abwaschen. " 


i24  SIXTH  INTERNATIONAL 

Teil  der  Behandlung  iiberwunden.  Die  Vermeidung  jeder 
Reibung  und  des  Kalten  Wassers  und  die  Verlegung  der  Reinigung 
auf  den  Abend  bessert  schon  jede  Rosacea  ohne  weiteren 
Gebrauch  von  Medikamenten  zusehends. 

Die  heisse  Abschreckung  ist  nicht  nur  als  Prophylaxe  und 
Therapie  derjenigen  Blutwallungen,  welche  durch  aussere 
Reize  hervorgerufen  werden,  von  grossem  Werte,  sondern 
ebenso  wirksam  bei  den  reflektorisch  erzeugten,  habituellen 
Blutwallungen.  Immerhin  ist  es  sehr  wiinschenswert,  dass 
wir  fur  diese  Falle  auch  ein  inneres  Mittel  besitzen,  welches 
durch  direkte  und  indirekte  Einwirkung  auf  die  Blutgefasse 
die  Neigung  zu  Blutwallungen  herabsetzt,  und  ein  solches 
besitzen  wir  seit  1884  im  Ichthyol.  Ich  wusste  kein  anderes 
und  ebenso  unschuldiges  Mittel  zu  nennen,  welches  im  Stande 
ware,  im  Laufe  einiger  Wochen  die  Wallungen  zum  Kopfe 
zu  mildern  und  zu  beseitigen.  Ob  es  sich  hierbei  um  eine 
direkte  Wirkung  vom  Blute  aus  auf  die  Gefasse,  oder  eine 
indirekte  handelt,  welche  von  anderen  Organen  aus  wirkt, 
ist  noch  unentschieden ;  wahrscheinlich  ist  beides  der  Fall. 
Denn  wenn  die  Wirkung  auch  bei  sonst  vollkommen  gesunden 
Organen  stets  eintritt,  so  ist  sie  doch  am  eklatantesten  bei 
solchen  weiblichen  Personen,  bei  denen  noch  eine  Reihe 
anderer  Organleiden  gleichzeitig  dadurch  gebessert  werden, 
wie  Anamie,  Muskelschwache,  Appetitlosigkeit,  Amenor- 
rhoe,  wie  ja  uberhaupt  magere,  blutarme,  appetit-  und 
kraftlose  Menschen  fur  den  Ichthyolgebrauch  pradestiniert 
sind.  Die  gleichzeitige,  unbestrittene  Regulierung  der  Darm- 
funktionen  und  der  Circulation l  ist  wohl  der  Haupthebel, 
mittels  dessen  das  Ichthyol  so  starken  Einfluss  auf  die 
Blutwallungen  gewinnt.  Eine  abfiihrende  Wirkung  besitzt 

1  Ich  mOchte  hier  citieren,  was  der  praktisch  so  erfahrene  Malcolm 
Morris  fiber  die  Vorzuge  des  inneren  Ichthyolgebrauches  bei  der  Rosacea 
sagt:  "After  the  removal  of  any  obvious  cause,  the  most  trustworthy  inter- 
nal remedy  is  ichthyol,  which  often  brings  about  a  marked  improvement 
after  even  a  few  days'  administration.  It  regulates  the  bowels,  prevents 
flatulence,  helps  the  digestion,  stops  the  reflex  flushing,  and  steadies  the 
circulation.  I  usually  begin  by  ordering  five  grains  in  capsules,  tabloids, 
or  pills,  to  be  taken  on  an  empty  stomach  early  in  the  morning  and  late  at 
night.  In  a  few  days  I  increase  the  dose  to  seven  grains,  and  afterwards 
to  ten  grains  and  upwards  until  the  desired  results  are  obtained."  (Malcolm 
Morris,  Diseases  of  the  Skin,  Cassell  &  Co.,  London,  1904,  p.  171.) 


DERMATOLOGICAL  CONGRESS  125 

Ichthyol  bekanntlich  nicht;  wo  eine  solche  indiziert  ist,  muss 
man  auf  anderem  Wege  nachhelfen.  Man  kann  das  Ichthyol 
in  uberzuckerten  Pillen  a  o.  i  gr.  oder  in  Kapseln  a  o.  5  gr. 
in  der  Tagesdosis  von  0.5-2.0  verabreichen  und  tut  immer 
gut,  mit  der  Dosis  allmahlich  zu  steigen.  Billiger  ist  die 
Verschreibung  in  wassriger  Losung  und  auch  in  manchen 
Beziehungen  besser.  Man  verordnet: 

Ichthyoli,  5 
Aq.  destillat.,  10 

Und  ein  Tropfglas.  S.  Dreimal  taglich  5-30  Tropfen  in 
Wasser  zu  nehmen. 

Man  tropft  zunachst  5  Tropfen  in  ein  Weinglas  und  giesst 
es  halb  oder  ganz  voll  mit  Wasser.  Am  besten  trinkt  man  noch 
etwas  Wasser  hinterher  oder  nimmt — wenn  der  Geschmack 
sehr  unangenehm  empfunden  wird — einen  Fruchtbonbon. 
Die  Darreichung  geschieht  am  besten  zwischen  den  Mahl- 
zeiten,  beim  Aufstehen,  mittags  und  abends  vor  dem  Zubette- 
gehen.  In  den  ersten  Tagen  pflegt  der  Magen  hin  und  wieder 
durch  Aufstossen  mit  Ichthyolgeschmack  zu  reagieren ;  solange 
bleibt  man  bei  der  Minimaldosis  von  5  Tropfen.  Nach  einigen 
Tagen  hat  sich  der  Magen  daran  gewohnt,  nun  steigt  man 
taglich  oder  jeden  2ten  Tag  um  einen  Tropfen,  nimmt  also 
3  mal  6,  7,  8  Tropfen  u.  s.  f.  bis  3  mal  30  Tropfen,  entsprechend 
1.5  Ichthyol.  Diese  Dosis  geniigt  in  fast  alien  Fallen,  wenn 
man  Ichthyol  in  wassriger  Losung  gibt  und  fiihrt  durch- 
schnittlich  in  3  Wochen  eine  erhebliche  Besserung  der 
Blutwallungen  herbei. 

Gleichzeitig  mit  der  Beseitigung  der  accidentellen  Schad- 
lichkeiten  muss  in  alien  Fallen  die  causale  Therapie  der 
Rosacea  eingeleitet  werden,  d.  h.  die  Beseitigung  der  wirklichen 
Krankheitsursachen.  Da  die  Rosacea  eine  Teilerscheinung 
des  seborrhoischen  Processes  ist,  so  zerfallt  die  causale 
Therapie  naturgemass  in  die  ortliche  Behandlung  der  Rosacea 
und  in  die  Beseitigung  aller  ubrigen  seborrhoischen  Erscheinun- 
gen,  welche  die  Rosacea  begleiten,  unter  denen  eine  Blepharitis 
ciliaris,  eine  Alopecia  seborrhoica  und  andere  Ekzemerschein- 
ungen  die  wichtigsten  sind.  Man  soil  den  Rosaceapatienten 


126  SIXTH  INTERNATIONAL 

nie  aus  der  Behandlung  entlassen,  ehe  auch  solche  Manifes- 
tationen  des  seborrhoischen  Ekzems  gnindlich  beseitigt  sind. 
Fur  die  Praxis  kann  man  die  Rosaceafalle  einfach  in  leichte 
und  schwere  einteilen.  Zu  ersteren  gehoren  diejenigen, 
welche  sich  in  hunter  Weise  aus  erythematosen,  schuppenden, 
vergilbten,  glatten  Flecken  zusammensetzen  und  bei  denen  nur 
wenige  Papeln  und  Pusteln  ausgebildet  sind.  Als  schwerere 
haben  diejenigen  zu  gelten,  bei  welchen  nach  langerem 
Bestande  eine  gleichmassige  Rotung  sich  in  diffuser  Weise 
iiber  den  grossten  Teil  des  Gesichtes  ausgebreitet  hat,  wo 
viele  Papeln  und  Pusteln  die  Oberflache  hockerig  auftreiben 
und  Venenektasien  reichlich  gebildet  sind. 

Das  einfachste  und  beste  Mittel  fur  die  leichteren  Falle  von 
Rosacea  ist  die  auch  sonst  bei  alien  seborrhoischen  Ekzemen 
hauptsachlich  gebrauchte  Zinkschwefelpaste.1  Nur  muss  sie 
wie  alle  Salben  und  Fasten  fur  das  Gesicht  durch  Zinnober 
rotlich  gefarbt  sein,  um  auch  bei  Tage  in  unauffalliger 
Weise  angewandt  werden  zu  konnen,  und  erhalt  zweck- 
massig  einen  kleinen  Zusatz  Vaseline,  da  alle  Pasten  bei 
Rosacea  ohne  Druck  und  Reibung,  nur  durch  einfaches 
Aufstreichen  auf  der  Haut  verteilt  werden  sollen. 

Man  verschreibt  also  etwa: 


Pastae  Zinci  sulfuratae  rubrae,  35 

Vaselini,  5 

Mf.  Pasta. 


Diese  Paste  wird  abends  nach  der  Reinigung  mit  heissem 
Wasser  appliciert  und  mit  einer  Mullbinde  niedergebunden 
(s.  oben.).  Kann  der  Tag  zur  Behandlung  benutzt  werden, 
so  streicht  man  sie  leicht  auf  die  befallenen  Stellen  auf,  solange 
man  zuhause  ist,  und  wischt  sie  ab,  bevor  man  ausgeht. 
Dann  wird  teils  zum  Schutz  gegen  die  Witterung,  teils  zur 

»  Zinci  oxydati,  14  Past.  Zinci  sulfur.,  99 

Sulfur  praec.,  10  Cinnabaris  i 

Terr,  siliceae,      4  Mf.  Pasta.    S.  Pasta  Zinci  sulfurata  rubra. 

Ol.  benzoinat.,  12 
Adipis  benzoinat.,  60 
Mf.  Pasta.     S.  Pasta  Zinci  sulfurata. 


DERMATOLOGICAL  CONGRESS  127 

Verdeckung  der  Salbenreste  ein  hautfarbener  Puder  1  auf  die 
Stellen  aufgewischt : 

Pulv.  cuticoloris,  9 

Ichthyoli,  i 

Mf.  Pulvis. 

Hierbei  muss  man  nicht  vergessen,  dem  Patienten  zu 
sagen,  dass  arzneiliche  Puder  nicht  mit  dem  Puderquast 
eingestaubt,  sondern  wie  eine  Salbe  mit  dem  Finger  sanft 
eingerieben,  bei  der  Rosacea  aber  nur  aufgetupft  werden. 
Nachdem  der  Ueberfluss  des  Puders  wieder  mit  einem  weichen 
Tuch  abgewischt  ist,  kann  der  Patient  ausgehen  und  ist  dann 
nicht  nur  in  unauffalliger  Weise  unter  andauernder  Behand- 
lung,  sondern  auch  ziemlich  gut  gegen  Witterungseinflusse 
geschtitzt.  Der  angegebene  Puder  ist  nicht  nur  sehr  brauch- 
bar  als  Tagesbehandlung,  sondern  stellt  auch  fiir  sich  allein 
eine  vollkommen  ausreichende  Tag-  und  Nachtbehandlung  fur 
die  leichtesten  Fdlle  von  Rosacea  dar,  so  insbesondere  fiir 
jene  ersten  umschriebenen  Rotungen  der  Nase,  mit  denen 
Patienten  die  auf  ihren  Teint  sehr  eigen  sind,  bereits  den  Arzt 
aufsuchen.  Man  kann  dann,  um  alles  Gute  in  einem  Recepte 
zu  vereinen,  dem  obigen  Puder  noch  etwas  Schwefel  zusetzen : 

Pulv.  cuticol.,  8 
Sulf.  praecip.,  i 
Ichthyoli,  i 
Mf.  Pulvis. 

Je  nach  dem  naturlichen  Fettgehalt  der  Gesichtshaut 
spater  oder  fruher  bedingt  der  andauernde  Gebrauch 
der  schwefelhaltigen  Paste  eine  kunstliche  Sprodigkeit  der 
Haut,  besonders  an  den  nicht  erkrankten  Stellen,  welche 
zu  einer  Modifikation  der  Behandlung  Anlass  gibt.  Anstatt 
die  Paste  fetthaltiger  zu  verschreiben,  tut  man  besser,  neben- 
her  Cold  Cream  in  der  Weise  brauchen  zu  lassen,  dass  der 
Patient  bei  jedesmaligem  Gebrauche  zuerst  das  ganze  Gesicht 

1  Boli  rubrae,  0.5 
Boli  albae,  2.5 
Magnes.  carbon.,  4.0. 
Zinci  oxydati.,  5.0 
Amyli  oryzae,  8.0 
Mf.  Pulvis  subt.     S.  Pulvis  cuticolor. 


128  SIXTH  INTERNATIONAL 

mit  Cold  Cream  einreibt  und  dann  auf  die  hauptsachlich 
befallenen  Stellen  etwas  von  der  Paste  daruber  streicht; 
auf  diese  Weise  wird  die  Gesamtsprodigkeit  beseitigt  und  der 
Rest  der  Affektion  gleichzeitig  weiterbehandelt.  Der  Patient 
lernt  es  bald,  die  Paste  mehr  und  mehr  durch  Cold  Cream  zu 
ersetzen,  je  naher  die  Heilung  ruckt,  die  durchschnittlich 
bei  leichten  Fallen  in  einigen  Wochen  erreicht  wird. 

In  den  schwereren  Fallen  ist  die  Grundbehandlung  dieselbe, 
nur  muss  der  oberflachlich  wirkenden  Zinkschwefelpaste 
das  tiefer  wirkende,  antiseborrhoische  Unguentum  resorcini 
compositum1  zu  Hilfe  kommen.  Man  verordnet  dasselbe 
entweder  nebenbei,  lasst  das  ganze  Gesicht  mit  Zinkschwe- 
felpaste behandeln  und  in  alle  schwerer  befallenen  dunkel- 
roten,  papulosen  und  pustulosen  Stellen  die  Resorcinsalbe 
dariiber^streichen,  oder  man  verschreibt  von  vornherein : 

Pastae  Zinci  sulfuratae  rubr.,  20-30 
Ung.  resorcini  compos.,  10-20 
Mf.  Pasta. 

Diese  sehr  bewahrte  Mischung  hat  noch  einige  praktische 
Vorteile,  auf  die  ich  aufmerksam  machen  mochte.  Der 
Vaselingehalt  der  Resorcinsalbe  gibt  der  Paste  die  fur  die 
Rosacea  erwiinschte  Konsistenz  und  der  Ichthyolgehalt 
derselben  gleichzeitig  einen  gelben  Stich,  der  die  ganze 
Mischung  der  naturlichen  Hautfarbe  ahnlicher  macht. 
Denn  vollkommen  hautfarben  werden  unsere  Salben  bekannt- 
lich  nur,  wenn  sie  die  drei  Hautfarben:  Weiss,  Gelb  und  Rot 
enthalten,  die  in  dieser  Mischung  durch  Zinkoxyd,  Ichthyol 
und  Zinnober  gegeben  sind.  Die  Folge  ist,  dass  grade  diese 
ausserst  wirksame,  starke  Mischung  ganz  gut  auch  bei  Tage 
ohne  alle  Bedeckung  im  Gesicht  gebraucht  werden  kann ;  man 
tragt  nur  ganz  wenig  von  derselben  auf  die  hauptsachlich 
befallenen  Stellen  auf  und  verstreicht  die  geringe  Quantitat 
sanft  mit  dem  Finger,  bis  sie  unsichtbar  geworden  ist.  Bei  den 
schwersten  Fallen  mit  universeller  dunkelroter  Gesichtsfarbe 
tragt  man  die  Mischung  abends  ziemlich  dick  auf,  bindet 

1  Resorcini,  Ichthyoli  aa  5 
Acidi  salicylici,  2 
Vaselini  flavi,  88 
Mf.  Unguent,  resorcini  compos. 


DERMATOLOGICAL  CONGRESS  129 

mit  einer  Mullbinde  ein  und  wischt  am  anderen  Morgen  ohne 
neue  Reinigung  der  Haut  die  Reste  mit  einem  weichen  Tuche 
ab;  die  auf  dem  Gesichte  bleibenden  Spuren  bilden  dann  eine 
ausreichende  Tagbehandlung  und  zugleich  sowohl  Schutz 
wie — durch  den  gelben  Ton — eine  hautfarbene  Schminke,  die 
gerne  mit  in  Kauf  genommen  wird.  Endlich  fuhrt  die 
Mischung  auch  nicht  so  leicht  eine  allegemeine  Sprodigkeit 
der  Haut  herbei  wie  die  einfache  Zinkschwefelpaste. 

Durch  diese  Pastenbehandlung  werden  mit  Sicherheit  und 
ohne  alle  Unannehmlichkeiten  fur  den  Patienten  alle  ein- 
zelnen  Symptome  der  Rosacea,  Rote,  Schuppen,  Vergilbung, 
Papeln  und  Pusteln,  bis  auf  die  Venenektasien  beseitigt; 
diese  treten  auf  der  blasseren  Haut  manchmal  zogar  nun  erst 
deutlich  hervor.  Sie  warden  durch  eine  sehr  lange  fort- 
gesetzte  Kur  auch  nur  wenig  beeinflusst  werden.  Man 
zogert  daher  in  diesem  Zeitpunkt  nicht  und  beseitigt  dieselben 
auf  einmal  in  moglichst  schonender  Weise  durch  den 
Mikrobrenner. l  Wahrend  der  Patient  sitzt  und  den  Kopf 
etwas  ruckwarts  fest  anlegt,  zieht  man  bei  schwach  glii- 
hendem  Platinbolzen  des  Mikrobrenners  mit  der  nicht  glu- 
henden,  aber  heissen,  zu  einem  Ringe  gekrummten  Spitze 
samtliche  Venen,  sanft  andriickend  und  genau,  nach.  Sie 
verschwinden  unter  dem  heissen  Druck  sofort,  indem  sie 
durch  das  anschwellende  kollagene  Gewebe  komprimiert 
werden,2  und  statt  ihrer  erscheinen  weissliche  Streifen  der- 
selben  Form,  die  aus  verbrannter  Hornschicht  bestehen. 
Eine  allgemeine  oder  ortliche  Narkose  habe  ich  zu  diesem 
Zwecke  nie  notig  gehabt.  Man  muss  sich  nur  erinnern,  dass 
die  Nervenendapparate  am  dichtesten  sich  an  der  Mund-  und 
Nasenoffnung  zusammendrangen,  daher  diese  Gegenden 
zuerst  meiden  und  statt  dessen  einzelne  Venen  der  seitlichen 
Wangen-  oder  oberen  Nasenpartie  zum  Verschwinden  bringen. 
Jeder  Patient,  der  einmal  sieht,  wie  rasch  die  roten  Adern  auf 
diese  Weise  unsichtbar  zu  machen  sind,  erlaubt  dann  gerne 
auch  die  Verodung  der  Venen  an  den  empfindlicheren  Stellen, 

1  Unna,  "Ueber  einen  neuen  Mikrobrenner  und  seine  Anwendung  bei 
der  Rosacea  und  anderen  Hautkrankheiten,"  Man.  f.  pr.  Dermal.,  Bd. 
x.,  1890,  pg.  32.  Der  Mikrobrenner,  Ebenda,  Bd.  xxvi.,  1898,  pg.  388. 

2s.  Unna,  Histopathologie  der  Haut,  pg.  81. 

VOL.  1—9 


i3o  SIXTH  INTERNATIONAL 

als  welche  ich  besonders  die  Nasenfliigel  und  das  Nasenseptum 
hervorhebe.  Die  Nachbehandlung  besteht  im  ofteren  Auf- 
tragen  des  obigen  hautfarbenen  Puders ;  dieses  hat  den  Zweck, 
die  gebrannten  Stellen  stets  trocken  zu  erhalten  und  als . 
trockene  Schorfe  sich  langsam  von  selbst  abstossen  zu  lassen. 
Deshalb  ist  auch  jedes  Reiben  und  Waschen  zu  widerraten, 
denn  es  wiirde  zur  Folge  haben,  dass  die  Gefasse  sich  wieder 
mit  Blut  fiillen  und  die  kleine  Operation  umsonst  war.  Nach 
8  Tagen  sind  die  Gefasse  stets  narbenlos  verodet,  wenn  sie 
gut  mit  dem  Mikrobrenner  nachgezogen  und  trocken  ge- 
halten  waren.  Dann  muss  der  Patient  sich  wieder  vorstellen 
und  eventuell  iibrig  gebliebene  Venen  auch  noch  veroden 
lassen. 

Dass  diese  unblutige,  einfache  und  sichere  Methode  den 
von  F.  Hebra  angegebenen  blutigen  der  Langsschlitzung  und 
der  queren  Zerschneidung  durch  seinen  Stichler  bei  weitem 
vorzuziehen  ist,  wird  jeder  zugeben,  der  beide  Methoden 
geubt  hat.  Aber  auch  die  neuerdings  von  mehreren  Seiten 
empfohlene  elektrolytische  Verodung  der  Venen  kann  sich, 
was  Muhelosigkeit  und  Schnelligkeit  betrifft,  nicht  mit  der 
Behandlung  durch  den  Mikrobrenner  vergleichen.  Die  mul- 
tiplen  Skarifikationen  Balmanno  Squires,  Entile  Vidals  und 
Veiels  gehoren  mit  den  ingeniosen  hierfur  erdachten  In- 
strumenten  ebenso  der  Geschichte  an  wie  die  Salpetersau- 
reatzungen  Naylers  und  die  Blutegel  und  Schropfkopfe  von 
Ambroise  Pare. 

Die  bisherige  Schilderung  der  Therapie  bezieht  sich  auf  die 
ambulatorische  Sprechstundenbehandlung.  Leichtere  Falle 
heilen  darunter  in  2-4  Wochen,  schwerere  aber  erst  in  2-4 
Monaten  und  es  entsteht  die  Frage,  ob  wir  nicht  auch  diese 
Falle  durch  eine  energischere  Haus-  oder  Klinikbehandlung 
ebenfalls  in  4-6  Wochen  zur  Heilung  bringen  konnen.  In 
der  Tat  ist  das  moglich  mittels  der  von  mir  1890  einge- 
fuhrten  Behandlung  durch  Schdlpasten1  und  sehr  begreiflich, 
wenn  wirklich  die  Rosacea  nur  eine  durch  die  Lokalisation 
modifizierte  Form  eines  oberflachlichen,  infektiosen  Ka- 
tarrhs  der  Haut,  einer  seborrhoischen  Oberhautentzundung 
ist.  Denn  mittels  mehrmaliger  Abschalung  beseitigen  wir 

«  Monatshefte  f.  pr.  Derm.,  Bd.  x.,  1890,  pg.  32. 


DERMATOLOGICAL  CONGRESS  131 

sicher   am   griindlichsten    samtliche   infektiose    Keime    zug- 
leich  mit  ihrem  Mutterboden,  der  verhornten  Oberhaut. 

Die  Schalpaste  (Pasta  lepismatica)  ist  eine  40-50% 
Resorcin  enthaltende  Zinkpaste,1  der  milderen  Wirkung 
wegen  gerne  Ichthyol  zugesetzt  wird,  wodurch  die  Paste 
allerdings  ein  braunes  Aussehn  gewinnt  und  fiir  den  am- 
bulatorischen  Gebrauch  ganz  ungeeignet  wird.  Doch  fur 
olen  Gebrauch  im  Hause  oder  in  der  Klinik  ist  die  gewohnliche 
Verschreibung : 

Pastae  Zinci 

Resorcini  subtil,  pulv.,  aa  20.0 
Ichthyoli 
Vaselini,  aa  5.0 
Mf.  Pasta.     S.  Pasta  lepismatica. 

Mit  dieser  Paste  wird  die  Gesichtshaut,  soweit  sie  er- 
krankt  ist,  zweimal  taglich  eingerieben.  Gleich  das  erste 
Mai  bildet  sich  eine  braunliche  Hornschwarte  unter  mehr 
oder  weniger  bedeutendem  Brennen ;  ist  diese  einmal  gebildet, 
so  empfindet  der  Patient  bei  den  spateren  Einreibungen  nur 
wenig  mehr.  Doch  kann  man  bei  empfindlichen  Patienten 
von  Anfang  an  2-5%  Anasthesin  der  Paste  zusetzen.  Die 
Paste  muss  stets  so  eingerieben  werden,  dass  keine  scharfen 
Rander  entstehen.  Nach  der  Haargrenze  und  samtlichen 
Schleimhauteingangen  hin,  besonders  auf  den  Augenlidern, 
muss  daher  mit  trockenem  Finger  der  Salbenrand  nur  leicht 
ausgestrichen  oder — wie  der  Kunstausdruck  heisst: — "  ver- 
duftet"  werden,  sonst  stechen  nach  der  Schalung  die  ge- 
schalten  und  ungeschalten  Partien  zu  stark  von  einander 
ab.  Man  bemuhe  sich  nicht  bei  umschriebenen  Rosacea- 
flecken,  nur  diese  oder  nur  die  Mittelpartie  des  Gesichtes 
schalen  zu  wollen;  die  Resultate  sind  trotz  der  grosseren 
Miihe  nicht  so  gut  wie  bei  Gesamtschalungen  der  Gesichts- 

1  Hierftir  empfehle  ich  nur  meine  Kieselgur  enthaltende,  nicht  die  offici- 
nelle  Zinkpaste,  da  die  starke  Eintrocknung  durch  Kieselgur  hier  als  Corrigens 
des  Resorcins  ndtig  ist.  Ihre  Formel  ist: 

Zinci  oxydati,  24 

Terrae  siliceae,  4 

Ol.  benzoinat.,  12 

Adipis  benzoinat.,  60 


i32  SIXTH  INTERNATIONAL 

haut.  Nachdem  das  Gesicht  auf  diese  Weise  drei  Tage 
hindurch  morgens  und  abends  behandelt  wurde,  ist  die 
Hornschwarte  von  geniigender  Starke,  um  als  eine  schreib- 
papierdicke  Membran  in  toto  sich  abzulosen.  Man  kann  dieses . 
unter  jeder  deckenden  Paste  abwarten.  Aber.  da  die  stark 
bewegten  Teile  um  den  Mund  zuerst  sich  ablosen,  ein- 
reissen  und  von  hier  aus  weiterreissend  die  Maske  sich 
in  einzelnen  Fetzen  ablosen  wurde,  so  tut  man  besser, 
vom  4~7ten  Tage  durch  Einwicklung  mit  Zinkichthyol- 
salbenmull  oder  Einpinselung  von  Zinkichthyolleim  (und 
Auftupfen  von  Watte)  eine  provisorische  Schutzdecke  her- 
zustellen.  Manche  Patienten  haben  nach  der  Schalung  ein 
Bediirfnis  nach  starker  Einfettung;  fur  diese  passt  der 
Salbenmull.  Anderen  ist  der  letztere  zu  warm  und  sie  ziehen 
die  Leimdecke  vor.  Am  raschesten  und  angenehmsten  voll- 
zieht  sich  die  Ablosung  der  Resorcinsschwarte,  wenn  man 
bei  Tage  und  bei  Nacht  zwischen  Salbenmull  und  Leim 
wechselt.  Keinenfalls  aber  darf  der  Patient  die  Membran 
stiickweise  abreissen  oder  die  Leimdecke  rasch  durch  Reiben 
mit  heissem  Wasser  entfernen  wollen. 1  Ist  am  7ten  Tage 
der  letzte  Rest  der  Resorcinschwarte,  der  gewohnlich  an 
der  Stirnhaargrenze  und  Nasenspitze  am  langsten  haftet, 
abgef alien,  so  prasentiert  sich  die  Gesichtshaut  viel  reiner, 
feiner,  blasser  und  glatter.  Auch  einzelne  der  kleineren 
Varicen  sind  verschwunden ;  zugleich  aber — ein  ungewollter, 
jedoch  nicht  minder  befriedigender  Nebenerfolg  —  samtliche 
Epheliden  und  sonstige  oberflachliche  Pigmentierungen. 
Das  Pigment  wandert  namlich,  vom  Resorcin  angelockt, 
in  die  resorcinierte  Hornschicht  hinein.  Kein  Wunder  daher, 
dass  besonders  die  Patienten  weiblichen  Geschlechts,  nach 
Wahrnehmung  dieser  sichtlichen  Hautverjungung  sich  gerne 
der  Wiederholung  der  Procedur  unterziehen.  Von  dieser 
Schalkur,  die  genau  eine  Woche  in  Anspruch  nimmt,  geniigen 
durchschnittlich  4  fur  die  schwereren  und  6  fur  die  aller- 
schwersten  Formen  der  Rosacea.  Wo  sehr  ausgedehnte 
Varicen  vorhanden  sind,  lasst  man  am  besten  in  der  Mitte 

1  Man  betupft  die  Leimdecke  mit  sehr  heissem  Wasser  alle  paar  Minuten 
und  lasst  dazwischen  abldihlen;  nach  einer  halben  Stunde  ist  der  Leim 
dann  auf  schonendste  Weise  entfernt. 


DERMATOLOGICAL  CONGRESS  133 

eine  Pause  von  einer  Woche  eintreten,  um  die  grosseren 
Varicen  samtlich  mit  dem  Mikrobrenner  zu  veroden. 

Nur  selten  besteht  fur  diese  Schalkur  eine  Contrain- 
dikation,  namlich  dann,  wenn  eine  Idiosynkrasie  gegen 
Resorcin  vorhanden  ist.  Dieses  bemerkt  man  gleich  am 
ersten  Tage  durch  starkes  Brennen,  Anschwellen  der  Haut 
und  Blasenbildung ;  es  kommt  nur  sehr  selten  vor.  In  solchem 
Falle  muss  sofort  die  Paste  abgewaschen  und  das  Gesicht  dick 
mit  Mehl  eingepudert  oder  eingebunden  werden,  bis  die 
Schwellung  vorbei  und  die  Blasen  eingetrocknet  sind.  Auch 
in  diesen  Fallen  stosst  sich  eine  unregelmassige  Resor- 
cinmembran  mit  sichtlich  gunstigem  Erfolge  fur  die  Rosacea 
ab;  aber  die  Weiterbehandlung  wird  man  dann  doch  mit 
Zinkschwefelpaste  durchfiihren. 

Die  bei  regelrechter  klinischer  Behandlung  ausgezeichneten 
Erfolge  der  Schalkur  veranlassen  manche  Patienten  zu  dem 
Wunsche,  sie  auch  bei  ambulatorischer  Behandlung  vom 
Arzte  durchgefuhrt  zu  sehen.  Da  es  dann  nicht  darauf  an- 
kommt,  auf  einmal  eine  moglichst  dicke  Hornmenbran  zur 
Abstossung  zu  bringen,  sondern  umgekehrt,  die  Abschalung 
moglichst  wenig  sichtbar  zu  machen,  wenn  die  Kur  sich 
auch  viel  langer  hinauszieht,  so  verdiinnt  man  die  Schal- 
paste  etwas  mit  Vaselin  und  lasst  naturlich  das  braunfar- 
bende  Ichthyol  weg.  Die  Formel  heisst  dann: 

Past.  Zinci 

Resorcini  subtil,  pulv.,  aa  20 

Vaselini,  10 

Mf.  Pasta. 

Die  Paste  wird  nur  Nachts  gebraucht.  Bei  Tage  wird 
sie  abgewischt,  worauf  man  die  Haut  einpudert.  Beim 
Waschen  abends  stossen  sich  jedes  Mai  einige  Hornlamellen 
ab,  und  wahrend  der  Kur  sieht  der  Teint  natiirlich  grade  nicht 
besonders  gut  aus;  doch  gibt  es  Patienten,  speziell  Herren, 
die  zur  eigentlichen  Schalkur  die  Zeit  nicht  hergeben,  welche 
sich  daraus  nichts  machen. 

Schon  wahrend  der  Behandlung  der  Rosacea  wird  man 
sich  um  etwaige  andere  seborrhoische  Affektionen  zu  kummern 
haben  und  diese  nach  und  nach  beseitigen.  Als  besonders 


i34  SIXTH  INTERNATIONAL 

wichtig  soil  die  Behandlung  der  in  nachster  Nachbarschaft 
der  Rosacea  lokalisierten  beiden  Affektionen:  Alopecia  se- 
borrhoica  und  Blepharitis  ciliaris  noch  in  Kiirze  betrachtet 
werden.  In  alien  Fallen  von  Rosacea,  speziell  der  Frauen, 
lasst  man  den  Kopf  waschen  und  dabei  einerseits  auf  Schuppen, 
auf  umschriebene  Ekzemherde  und  andererseits  auf  den 
Haarausfall  achten ;  sehr  oft  bestehen  hier  Abweichungen  von 
der  Norm,  deren  sich  die  Patienten  nicht  bewusst  sind.  In 
den  leichteren  Fallen  genugt  dann  die  Anwendung  einer 
Schwefelpomade  und  ofteres  Waschen.  Sind  schuppige  Herde 
oder  ist  starkerer  Haarausfall  vorhanden,  so  sind  Einreibungen 
mit  folgender  Pomade  empf ehlenswert : 

Ung.  pomadin.  sulfurati1 
Ung.  resorcini  compos.,  aa  20 
Mf.  Pomade. 

Bei  starker  Fettabsonderung  tritt  an  Stelle  der  Schwefel- 
salbe  besser  eine  Zinkschwefelpaste : 

Pastae  Zinci  sulfurat.,  20 
Ung.  resorcini  compos.,  10 
Mf.  Pomade. 

Diese  Pomaden  werden  taglich  in  die  gescheitelte  Kopf- 
haut  eingerieben,  und  nach  einigen  Tagen  wird  beim  Waschen 
Haarausfall  und  Beschaffenheit  der  Kopfhaut  gepriift.  Man 
wird  hierunter  von  einer  Waschung  zur  andern  eine  stetige 
Besserung  wahrnehmen. 

Die  Blepharitis  ciliaris  erfordet,  da  die  Conjunctiva  Schwe- 
fel  nicht  gut  vertragt,  statt  dessen  Resorcin,  Ichthyol  oder 
Quecksilberoxyd.  Als  Grundlage  der  Augensalben  dient 
Zinksalbe,  der  man  von  diesen  Medikamenten  einzeln  oder 
kombiniert  je  2-5%  hinzufugt.  Vor  dem  Einschlafen  wird 
die  Salbe  auf  die  geschlossenen  Lidkanten  sanft  eingerieben. 
Wenn  die  Cilien  durch  besonders  festhaftende  Krusten  verk- 
lebt  sind,  werden  Nachts  uber  der  Salbe  noch  Priessnitzsche 

1  Ol.  Cacao  30 
Ol.  amygdal.  benz.,  65 
Sulf.  praec.,  5 
Ol.  Rosae,  gtt.  II 
Extrait  Violette,  Reseda,  Jasmin,  aa  gtt.  40 


DERMATOLOGICAL  CONGRESS  135 

Umschlage  gemacht  mit  Kamillenthee  oder  i%iger  Resor- 
cinlosung  statt  Wasser.  Fur  die  fast  stets  vorhandene 
Conjunctivitis  ist  das  haufige  Eintraufeln  einer  Pyraloxin- 
losung1  am  meisten  empfehlenswert : 

Pyraloxini,  0.01-0.05 
Aq.  boracis 
Aq.  foeniculi,  aa  5.0 
Mf.  Augentropfen 

Ich  habe  mit  Hilfe  derselben  chronische  Conjunctivitiden 
ausheilen  sehen,  die  arztlicherseits  bereits  aufgegeben  waren. 

In  Bezug  auf  die  Beurteilung  und  Behandlung  anderer 
die  Rosacea  komplicierender  Ekzemformen  verweise  ich  auf 
meine  Ekzemmonographie. 2  Doch  sei  hier  kurz  bemerkt, 
dass  die  oben  angegebene  Mischung  von  Zinkschwefelpaste 
mit  komponierter  Resorcinsalbe  fast  in  alien  Fallen  diese 
Komplikationen  am  schnellsten  beseitigt. 

Die  Behandlung  der  Rosacea  mit  Schwefelpraparaten 
ist  keine  neue;  schon  Anthony  Todd  Thomson  (1778-1849),  der 
Zeitgenosse  Willans  und  Batemans,  empfahl  gegen  sie  Schwefel 
als  Puder,  und  seither  hat  derselbe  stets  eine  Rolle  in  der 
Rosaceatherapie  gespielt;  aber  er  wurde  nicht  fur  das 
angesehen,  was  er  wirklich  ist,  namlich  ein  Specificum,  ein 
Antiseborrhoicum  ersten  Ranges.  Nur  dadurch  ist  es  zu 
erklaren,  dass  man  glaubte,  er  musse  "durch  Entziindung" 
wirken,  wie  es  beispielsweise  Wolff  in  seinem  Lehrbuch  gradezu 
ausspricht.  Die  von  mir  angegebene  Behandlung  vermeidet 
vielmehr  alle  Reize,  die  zur  Entziindung  und  auch  nur  zur 
Blutwallung  fiihren,  auf  das  sorgsamste.  Damit  stellt  sich 
die  Rosaceabehandlung  auch  erst  in  den  richtigen  Gegensatz 
zur  Aknebehandlung,  bei  welcher  der  Schwefel  ebenfalls 
specifisch  wirkt,  aber  nur  unter  Beihilfe  starker,  Hornschicht 
erweichender  und  hyperamisierender,  chemischer  und  Horn- 
schicht verdunnender,  reibender  und  schabender,  mechanischer 
Mittel.  Die  Heilung  der  Akne  und  der  Rosacea  geschieht 
also  nicht,  wie  Brocq  will,  mittelst  derselben  Mittel,  sondern 

1  Pyraloxin     ist     oxydiertes    Pyrogallol    (erhaltlich    von    der    Schwan- 
apotheke,  Hamburg). 

2  Pathologie  und  Therapie  des  Ekzems.  Wien,  Holder,  1903. 


136        SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

trotz  des  gleichen  Specificums  auf  diametral  verschiedenen 
Wegen. 

Mit  Recht  hat  von  jeher  der  praktische  Arzt  dem  Schlusse 
ex  juvantibus  ein  grosses  Gewicht  beigelegt.  Ich  betrachte 
es  deshalb  als  eine  schone  Bestatigung  der  hier  nieder- 
gelegten  Anschauung  tiber  die  Grundverschiedenheit  zwischen 
Rosacea  und  Akne,  dass  auch  die  beste  und  rationellste 
Behandlungsart  beider  Affektionen  eine  diametral  entgegen- 
gesetzte  ist. 


DIE  KOMPLEMENTABLENKUNG  BEI  GONOR- 
RHOE  UND  HAUTKRANKHEITEN 

VON  DR.  R.  MULLER  UND  PRIVATDOCENT  DR.  MORIZ  OPPENHEIM, 

WIEN 

Im  Serum  von  Tripperkranken  kreisen  Substanzen, 
welche  man  mit  der  Komplementablenkungsmethode  nach- 
weisen  kann.  Zuerst  von  den  Verfassern  im  Serum  eines  an 
Arthritis  gonorrhoica  Erkrankten  nachgewiesen.  Dieser  erst- 
malige  einwandfreie  Nachweis  von  Antikorpern,  die  durch 
den  Gonococcus  produzirt  werden,  wurde  von  Bruck  und 
spater  von  Vanned  bestatigt.  Diese  Antikorper  lassen  sich 
auch  bei  Epididymitis  gonorrhoica,  Prostatitis  und  Metritis 
und  Endometritis  gonorrhoica  nachweisen,  doch  ist  das 
Vorhandensein  nicht  konstant.  Es  gibt  Menschen  bei  denen 
das  Serum  an  und  fiir  sich  hemmend  auf  die  Hamolyse 
wirkt.  Unter  diesen  Seren  stammten  die  grossere  Mehrzahl 
von  Psoriatikern. 


LE  GRATTAGE  METHODIQUE  COMME  PROCEDE 

DE   DIAGNOSTIC  DANS   CERTAINES 

DERMATOSES 

PAR  LE  DOCTEUR  L.  BROCQ,  PARIS 

Dans  une  pre'ce'dente  publication,  nous  avons  fait  con- 
naitre  en  quoi  consiste  cette  me"thode,  quels  sont  les  instru- 
ments qu'il  convient  d'avoir  pour  la  bien  appliquer  (curette 
spe"ciale  a  bords  mousses,  papier  a  cigarette,  linge  fin  et  blanc, 
compresseur  de  verre). 

Nous  avons  pr6cise*  quels  sont  les  renseignements  que 
cette  me'thode  peut  donner:  (caracteres  des  squames,  leur 
adherence,  leur  stratification,  1'aspect  du  corps  muqueux 
de  Malpighi,  la  presence  ou  1'absence  de  la  pellicule  sous- 
squameuse  de  L.  Duncan  Bulkley,  le  degre"  de  se'cheresse  ou 
d'exos6rose  qui  existe  au  niveau  de  la  couche  de  Malpighi, 
1'existence  ou  1'absence  de  ve"sicules  minuscules  intrae"pider- 
miques,  de  purpura  traumatique,  ou  de  fines  he'morragies, 
etc.  .  .  .)•  Enfin  nous  avons  donne"  un  bref  re'sume'  des 
caracteres  principaux  qu'offrent  certaines  dermatoses  sou- 
mises  &  ce  grattage  methodique. 

Dans  la  pre"sente  communication  nous  voulons  insister 
sur  quelques  points  particuliers  qui  nous  paraissent  avoir 
une  assez  grande  importance. 

i.  Quand  on  a  enleve"  doucement,  couche  par  couche,  les 
squames  s&ches  qui  recouvrent  le  corps  muqueux  dans  une 
dermatose  squameuse  comme  le  psoriasis,  ou  les  syphilides 
papulo-squameuses  par  exemple,  on  se  trouve  dans  certains 
cas  en  presence  d'une  surface  rouge,  plus  ou  moins  lisse, 
qui  peut  £tre  a  peu  seche,  ou  qui  peut  laisser  sourdre  de  la 
se'rosite'.  Quand  elle  est  peu  abondante,  cette  s£rosit<§  est 
perceptible  grace  k  un  papier  de  soie  que  Ton  applique  sur  la 
surface  mise  a  nu  et  qui  s'impr&gne  des  moindres  parcelles 
de  liquide  exsude*.  Cette  exose"rose  est  parfois  extr£mement 

137 


138  SIXTH  INTERNATIONAL 

abondante  comme  dans  certaines  syphilides,  dans  certaines 
formes  de  psoriasis  irritable. 

Son  degre  d'intensite  semble  etre  en  relation  avec  le  degre 
de  congestion  qui  existe  au  niveau  des  parties  atteintes,  et 
il  n'est  pas  indifferent  d'en  £tre  averti  au  point  de  vue  du 
pronostic  et  au  point  de  vue  du  traitement. 

II  y  a  des  dermatoses  rouges  et  squameuses  comme  les 
parapsoriasis  en  plaques  (6rythrodermies  pityriasiques  en 
plaques  diss&nine'es)  ,  comme  les  parak&ratoses  psoriasiformes 
seches  dans  lesquelles  apres  le  grattage  me'thodique  des  squames 
superficielles  on  ne  d6cele  que  peu  ou  point  d'exos6rose.  On 
peut  traiter  d'emble'e  ces  Eruptions  par  les  topiques  les  plus 
energiques,  par  les  preparations  pyrogaliees  ou  chrysopha- 
niques,  sans  courir  trop  le  risque  de  voir  se  developper  des 
poussees  6rythemateuses  ou  des  erythrodermies  exfoliantes 


Par  centre  il  y  a  des  eczemas,  des  eczemas  seborrheiques 
vrais  ou  parak^ratoses  psoriasiformes  ayant  de  la  tendance 
a  la  vesiculation,  des  psoriasis,  qui  des  qu'ils  sont  grattes 
me'thodiquement  offrent  le  ph^nomene  de  1'exoserose  a  un 
degre  tres  accentue.  On  doit  alors  se  defier  des  topiques  tres 
energiques:  en  employant  d'emblee  dans  ces  cas  des  prepara- 
tions mercurielles,  ou  pyrogallees  ou  chrysophaniques,  on 
peut  deVelopper  des  pouss^es  inflammatoires  considerables 
et  m6me  de  veritables  crises  de  dermatite  exfoliative.  On 
doit  done  dans  ces  cas  ou  le  processus  exoserotique  est  tres 
accentue  proceder  avec  prudence,  commencer  par  prescrire 
des  topiques  relativement  peu  irritants,  puis  s'61ever  pro- 
gressivement  dans  la  serie  des  topiques  actifs  a  mesure  que 
Ton  voit  qu'ils  sont  supportes. 

Je  dois  dire  cependant  que  dans  la  plupart  de  ces  der- 
matoses a  exos^rose  abondante  les  badigeons  de  goudron  de 
houille  pur  faisant  vernis  a  la  surface  des  teguments  donnent 
d'excellents  r^sultats,  et  sont  presque  toujours  admirablement 
support's  pourvu  que  Ton  se  conforme  aux  regies  suivantes. 
Apres  un  premier  badigeon  fait  de  maniere  a  couvrir  toute 
la  partie  malade  d'une  couche  assez  epaisse  de  goudron  pur, 
on  laisse  secher,  on  poudre  par-dessus  avec  beaucoup  de  talc, 
et  on  recouvre  de  tarlatane  aseptique  ou  de  toile  fine  et  blanche. 


DERMATOLOGICAL  CONGRESS  139 

Des  le  lendemain  on  applique  une  pate  de  zinc  additionne'e 
d'un  dixieme  d'ichthyol,  et  on  continue  ce  pansement  jusqu'a 
ce  que  tout  vestige  de  goudron  ait  disparu,  c'est-a-dire  pendant 
un  laps  de  temps  qui  varie  de  4  a  6  jours.  Alors,  mais  alors 
seulement,  on  fait  un  nouveau  badigeon  de  goudron  que  Ton 
fait  suivre  d'une  nouvelle  pe'riode  d'application  de  pate  de  zinc 
ichthyolee,  et  ainsi  de  suite  jusqu'a  guerison. 

2.  Parmi  les  phenomenes  que  produit  le  grattage  et  que 
Ton  peut  etudier  pour  aider  au  diagnostic  des  dermatoses, 
il  en  est  surtout  un  qui  nous  parait  avoir  dans  certains  cas 
une  importance  considerable  et  qui  n'a  pas  cependant  jusqu'ici 
attire  1' attention  des  dermatologistes :  nous  voulons  parler  du 
purpura  traumatique. 

Nous  avons  demontre  que  lorsqu'on  explore  par  le  grattage 
methodique  une  papule  initiale  de  lichen  plan,  une  de  ces 
papules  neoplasiques  caracteristiques,  polygonales,  d'un  rouge 
un  peu  bistre,  aplaties,  brillant  aux  incidences  de  lumiere, 
on  voit,  quand  on  precede  avec  le'gerete',  sans  brutalite^  survenir, 
entre  le  trentieme  et  le  soixantieme  coup  de  curette  en 
moyenne,  un  fin  purpura,  qui  apparait  tout  d'abord  a  la 
periph6rie  de  la  papule,  et  qui  s'elargit  peu  a  peu,  puis  se 
multiplie,  a  mesure  que  Ton  donne  de  plus  en  plus  de  coups 
de  curette. 

Or,  si  Ton  traite  de  me'me  une  plaque  de  lichemfication  pure, 
c'est-a-dire  1'ancien  lichen  simplex  chronique  des  auteurs 
fran§ais,  ou  nevrodermite  chronique  circonscrite  de  Brocq  et 
Jacquet,  notre  Prurit  circonscrit  avec  lich&iification,  on  voit 
que  la  surface  malade  supporte  avec  une  merveilleuse  facilite" 
les  coups  de  curette,  et  qu'il  faut  souvent  arriver  jusqu'a 
200  coups  de  curette  et  meme  davantage  pour  provoquer 
1'apparition  de  purpura  traumatique. 

Ce  fait  a  une  re"elle  importance,  car  beaucoup  de  dermatolo- 
gistes, surtout  en  Angleterre  et  en  AmeYique,  confondent  les 
varie'te's  papuleuses  du  lichen  simplex  chronique  ou  Prurit 
circonscrit  avec  lichenification  avec  le  lichen  plan.  Les  deux 
affections  sont  cependant  totalement  diSc"  rentes  1'une  de 
1'autre  comme  nature  et  comme  histologie.  Le  grattage 
methodique  permet  de  les  distinguer  avec  assez  de  facilit6  sans 
avoir  recours  a  1'examen  histologique.  Si  Ton  voit  paraitre 


i4o  SIXTH  INTERNATIONAL 

rapidement,  a  la  pe'riphe'rie  d'un  element,  du  purpura  trau- 
matique  entre  le  trentieme  et  le  soixantieme  coup  de  curette 
16gerement  donnas,  c'est  qu'il  s'agit  d'un  lichen  plan;  si  Ton 
d6passe  le  centieme  et  surtout  le  cent  cinquantieme  coup  de 
curette  sans  qu'il  se  soit  produit  de  purpura,  c'est  qu'il  s'agit 
d'un  lichen  simplex  chronique. 

3.  Mais  c'est  surtout  dans  les  syphilides  psoriasiformes 
secondaires  ou  tertiaires  que  1'apparition  rapide  du  purpura 
sous  Faction  de  la  curette  nous  parait  avoir  une  importance 
diagnostique  considerable. 

Quand  on  pratique  le  grattage  m6thodique  au  niveau 
d'une  papulo-squame  psoriasiforme  de  syphilis  secondaire, 
voici  ce  que  Ton  constate.  Les  squames  seches  qui  recouvrent 
la  lesion  sont  relativement  adh6rentes;  elles  r^sistent  a  la 
curette  quand  elle  est  maniee,  comme  on  doit  le  faire,  avec 
delicatesse.  Elles  ne  s'effrittent  jamais  avec  la  meme  facilite 
que  dans  le  psoriasis.  Mais  assez  rapidement,  plus  vite  que  lors- 
qu'il  s'agit  de  lichen  plan,  au  bout  du  quinzieme  ou  du  trentieme 
coup  de  curette,  parfois  meme  plus  tot,  on  voit  se  produire. 
a  travers  les  squames,  des  taches  punctiformes  d'un  rouge 
vif,  qui  ne  disparaissent  pas  par  la  pression  du  doigt  ou  du 
compresseur,  et  qui  sont  des  elements  de  purpura.  Dans 
la  plupart  des  cas  ce  purpura  est  relativement  volumineux, 
assez  irregulier  de  dimensions,  notablement  plus  irregulier  et 
plus  considerable  de  dimensions  que  celui  que  1'on  observe  dans 
le  psoriasis.  II  semble  en  outre  que,  quand  on  cesse  de  gratter, 
lorsqu'il  y  a  deja  quelques  points  minuscules  de  purpura 
produits,  ces  points  augmentent  pendant  quelques  secondes 
de  nombre  et  surtout  de  volume,  en  quelque  sorte  spontane- 
ment,  sans  qu'on  ait  donn6  de  nouveaux  coups  de  curette. 

Si  1'on  continue  ensuite  a  gratter  avec  la  curette,  on  finit 
par  enlever  les  dernieres  couches  de  squames,  et  1'on  provoque 
alors  de  petites  h6morragies.  Ces  hemorragies  se  produisent 
d'embiee,  des  le  d6but  du  grattage,  si  Ton  a  la  main  trop 
lourde,  et  si  Ton  arrache  violemment  les  squames  adhe"rentes; 
elles  sont  relativement  abondantes,  et  ne  ressemblent  nulle- 
ment  au  fin  piquete  he"morragique  du  psoriasis. 

Dans  certains  cas  I'adh^rence  des  squames  et  la  fragilite" 
de  la  derniere  cuticule  sont  telles  dans  les  syphilides  qu'il 


DERMATOLOGICAL  CONGRESS  141 

est  presque  impossible  de  ne  pas  provoquer  cet  accident  des 
les  premiers  coups  de  curette.  II  suffit  alors  parfois  de  frotter 
ces  papulo-squames  avec  la  pulpe  de  1'index  garni  d'un  pro- 
tecteur  en  caoutchouc  pour  voir  se  produire  du  purpura 
traumatique  dans  les  elements  eruptifs  a  travers  les  squames 
intactes,  et,  nous  insistons  encore  sur  ce  fait,  apres  avoir  cesse 
de  frotter,  si  1'on  examine  soigneusement  I'eleinent,  on  voit 
pendant  quelques  secondes  le  purpura  continuer  a  se  pro- 
duire, augmenter  d'intensit£  sans  autre  nouveau  traumatisme: 
ce  purpura  est  en  quelque  sorte  progressif,  ce  qui  ne  s'ob- 
serve  pas  dans  le  psoriasis,  du  moins  a  un  degr6  aussi  accentue". 

Certains  elements  papulo-squameux  de  syphilis  secondaire 
ont  au  contraire  a  leur  surface  des  squames  ou  des  croutelles 
peu  adherentes.  On  les  enleve  facilement  avec  la  curette. 
On  arrive  alors  sur  une  surface  lisse  d'un  rouge  assez  vif  ou 
d'un  rouge  bistre,  nettement  neoplasique  a  la  vue  et  au  toucher; 
elle  est  parfois  le  siege  d'une  exose'rose  plus  ou  moins  accen- 
tuee.  II  semble  vraiment  qu'en  proc6dant  au  grattage  me'tho- 
dique,  on  enleve  parfois  dans  ces  cas  une  derniere  cuticule 
d6collable;  cependant  jamais  elle  n'a  la  meme  nettete  que 
dans  le  psoriasis:  mais  il  est  incontestable  qu'on  arrive  a 
avoir,  comme  dans  le  psoriasis,  une  surface  rouge,  lisse  et 
luisante.  A  partir  de  ce  moment,  1'exploration  de  la  lesion 
devient  fort  delicate ;  il  ne  faut  proce"der  qu'avec  la  plus  extreme 
le'gerete'.  Si,  en  s'inspirant  de  ces  principes,  on  continue  a 
effleurer  la  surface  ainsi  desquame'e,  on  voit  tout  d'abord  se 
produire  ga  et  la  en  certains  points  de  rinfiltrat  sp6cifique  de 
petits  points  de  purpura  traumatique  que  de  nouveaux  coups 
de  curette  font  rapidement  grossir.  Cependant  il  peut  sur- 
venir  aussi  tout  de  suite  des  he'morragies,  mais  elles  sont 
abondantes,  et  ne  ressemblent  nullement  aux  h£morragies 
punctiformes  du  psoriasis.  Assez  souvent  I'exos6rose  qui  se 
produit  au  niveau  des  surfaces  d^pouille'es  de  squames  est 
16gerement  teinte'e  de  rose. 

Quand  on  explore  de  la  meme  maniere  avec  la  curette 
des  syphilides  psoriasiformes  circine'es  tertiaires,  c'est-a-dire 
des  syphilides  tuberculo-squameuses  circine'es,  on  observe 
la  me'me  filiation  de  phenomenes.  En  grattant  les  placards 
avec  soin,  on  enleve  dans  la  majorite"  des  cas  quelques  squames 


i42  SIXTH  INTERNATIONAL 

e'pidermiques  seches,  mais,  assez  rapidement,  des  le  dixieme,  le 
vingtieme,  le  trentieme  coup  de  curette,  a  travers  les  couches 
e'pidermiques  qui  adherent  encore,  on  voit  se  produire  des 
taches  de  purpura  traumatique  qui  s'accentuent  rapidement 
a  mesure  qu'on  continue  a  gratter;  des  qu'on  enleve  les  der- 
nieres  couches  d'e'piderme  corne\  on  provoque  1'apparition  de 
petites  h^morragies.  Mais  assez  sou  vent  aussi,  des  les  pre- 
miers coups  de  curette,  quel  que  soit  le  soin  avec  lequel  on 
precede,  on  dechire  le  corps  papillaire  en  soulevant  une 
squame  et  Ton  determine  ainsi  une  hemorragie  relativement 
considerable.  Dans  ces  cas  de  corps  papillaire  tout  parti- 
culierement  friable,  il  existe  presque  tou jours  un  processus 
d'exos6rose  fort  accentue". 

On  sait  que  dans  les  p£riodes  avanc£es  de  la  syphilis  on 
peut  observer  des  eruptions  psoriasiformes  circine'es,  relative- 
ment superficielles,  que  nous  avons  d6signees  sous  le  nom  de 
quaternaires.  Elles  se  voient  surtout  chez  les  personnes  agees. 
Par  leur  circination,  par  leur  superficiality  et  par  leur  nombre, 
elles  rappellent  tout-a-fait  1'aspect  des  psoriasis  circines. 
Les  r6sultats  que  donne  le  grattage  m6thodique  de  ces  lesions 
sont  moins  nets  que  dans  les  formes  pr6c6dentes :  le  purpura 
traumatique  que  Ton  produit  ainsi  nous  a  paru,  dans  les 
quelques  cas  que  nous  avons  pu  explorer  jusqu'ici,  etre  plus 
fin,  plus  discret  que  dans  les  syphilides  psoriasiformes  secon- 
daires  et  tertiaires  vulgaires.  Mais  dans  ces  cas  nous  avons 
presque  tou  jours  vu  ce  purpura  traumatique  se  produire 
avant  rhemorragie  punctiforme. 

En  somme,  d'une  maniere  g6nerale,  la  filiation  des  phe'no- 
menes  que  Ton  observe  quand  on  pratique  le  grattage  metho- 
dique  a  la  curette  au  niveau  d'une  syphilide  psoriasiforme 
est  la  suivante: 

(a)  Ablation  parfois  facile,  plus  sou  vent  assez  difficile, 
de  squames  cornees  beaucoup  moins  friables  et  beaucoup 
moins  stratifiees  que  celles  du  psoriasis  typique;  (6)  absence 
constante  ou  presque  constant e  de  la  fine  pellicule  transparente, 
de"collable  par  lambeaux  de  L.  Duncan  Bulkley;  (c)  apparition 
habituelle,  avant  que  Ton  ait  totalement  enlev6  les  squames 
e"pidermiques  adhdrentes,  de  points  accentue"s,  souvent  ir- 
r6guliers  de  dimensions,  de  purpura  traumatique ;  (d)  apparition 


DERMATOLOGICAL  CONGRESS  143 

ult6rieure  d'h^morragies  relativement  assez  abondantes  des 
que  Ton  a  enleve  les  dernieres  squames  cornees  et  dechire" 
la  derniere  pellicule. 

En  resume:  Les  caracteres  permettent  dans  la  majorite  des 
cas  de  distinguer  assez  facilement  un  element  de  psoriasis 
typique  d'un  element  de  syphilide  psoriasiforme.  Dans  le 
psoriasis  typique  on  arrive,  apres  avoir  enlev6  une  derniere  fine 
pellicule  d6collable  par  lambeaux  minuscules  ou  assez  impor- 
tants,  sur  une  surface  rouge,  lisse,  luisante,  sur  laquelle  apparait 
tout  d'abord  un  fin  piquete"  hemorragique :  le  purpura  succede 
a  ce  piquet^  hemorragique,  parfois  survient  simultane'ment : 
cependant  pendant  les  premiers  jours  des  pouss£es  aigues  de 
psoriasis  il  est  possible  de  deceler  tout  d'abord  par  le  grattage 
du  fin  purpura  au  niveau  des  elements  de  psoriasis  avant 
que  les  he"morragies  ne  paraissent ;  mais  ce  purpura  du  psoriasis 
est  tou jours  fin,  minuscule,  en  quelque  sorte  punctiforme  et 
bien  limited 

Dans  les  syphilides  psoriasiformes  le  grattage  fait  apparaitre 
rapidement,  sou  vent  avant  V  ablation  totale  des  squames,  du 
purpura  traumatique  irregulier,  relativement  considerable 
et  progressif,  dans  rinfiltrat  spe'cifique;  et  ce  n'est  qu'apres 
1'apparition  de  ce  purpura  que  se  produit  I'he'morragie,  a 
moins  que  Ton  n'ait  de'chire'  brutalement  toute  la  couche 
6pidermique  par  un  coup  de  curette  malencontreux ;  il  faut 
alors  proc^der  a  une  autre  exploration.  II  y  a  cependant  des 
cas  ou  la  friabilite*  des  tissus  est  si  grande  que  Themorragie  se 
produit  tout  de  suite,  mais  alors  elle  le  fait  avec  une  facilite" 
et  une  abondance  que  Ton  n'observe  pas  dans  le  psoriasis  vrai. 


ON    THE   VALUE    OF   AN    ABSOLUTELY   VEGE- 
TARIAN DIET  IN  PSORIASIS 

BY  DR.  L.  DUNCAN  BULKLEY,  OF  NEW  YORK 

Although  psoriasis  is  one  of  the  most  clearly  defined  and 
well  recognized  of  all  diseases  of  the  skin,  and  has  been  the 
subject  of  much  study,  clinically  and  microscopically,  we  are 
still  quite  in  the  dark  as  to  its  true  nature  and  etiology ;  more- 
over, good  observers  are  by  no  means  all  agreed  as  to  whether 
it  is  a  local  disease  of  the  skin  or  one  of  internal  origin.  Certain 
it  is  that  no  one  definite  cause  has  yet  been  established. 

The  appearance  and  character  of  the  individual  lesions 
have  time  and  again  suggested  a  parasitic  origin,  but  as  yet 
no  micro-organism  has  been  demonstrated  by  which  the 
eruption  can  be  produced  artificially;  nor,  on  the  other  hand, 
has  any  one  constitutional  state  been  shown  to  be  always 
productive  of  the  eruption.  Certain  observers  have,  there- 
fore, characterized  it  as  a  local  affection  of  the  skin  itself,  a 
misbehavior  of  its  cellular  elements,  even  as  epithelioma  is 
recognized  as  such. 

But  there  are  many  facts  and  features  of  the  disease  which 
point  to  its  not  being  a  purely  local  disease  of  the  skin,  but 
show  that  it  is  due  to  some  underlying  constitutional  state 
or  condition,  which  at  one  time  or  another  favors  the  de- 
velopment of  the  lesions  on  the  skin.  Not  to  lay  too  much 
stress  on  the  clinical  observations  of  many  in  regard  to  the 
connection  of  psoriasis  with  rheumatism  and  gout,  hereditary 
or  acquired,  or  the  appearance  of  the  eruption  after  vaccina- 
tion, the  exanthemata,  debilitating  illnesses,  prolonged  lacta- 
tion, etc.,  etc.,  there  are  some  peculiar  features  which  cannot 
be  ignored.  Thus,  the  intermittent  character  of  the  eruption, 
often  without  treatment,  shows  some  change  in  the  individual 

144 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS        145 

which,  even  on  the  theory  of  a  microbic  origin  of  the  separate 
lesions,  causes  the  omnipresent  micro-organisms  to  have 
effect.  Also,  the  well  known  proclivity  of  the  eruption  to 
appear  at  certain  seasons  of  the  year,  at  which  we  know  that 
the  diet  and  mode  of  life  vary  greatly,  points  to  a  systemic 
change  or  a  modification  of  the  metabolic  processes  favoring 
the  eruption. 

One  of  the  most  striking  facts  in  regard  to  the  production 
of  the  eruption  of  psoriasis  is  that  relating  to  the  subject  of 
this  paper.  Almost  twenty  years  ago,  at  the  First  International 
Dermatological  Congress,1  held  in  Paris,  in  a  "  Clinical  Study 
and  Analysis  of  One  Thousand  Cases  of  Psoriasis, "  I  stated 
that  "excessive  meat-eating  will  also  increase  the  disease, 
which  will  frequently  yield  with  much  greater  rapidity,  under 
the  same  treatment  as  before,  when  the  amount  of  meat  taken 
is  lessened,  or  when  it  is  entirely  cut  off,"  as  I  had  observed 
in  private  cases  for  some  years.  In  1895,  from  a  clinical 
study  of  three  hundred  and  sixty-six  cases  of  psoriasis  in 
private  practice,2  I  made  the  same  statement,  adding  "I  have 
a  considerable  number  of  psoriatic  patients  who  have  taken 
no  meat,  or  only  a  very  little  fish  and  white  meat  of  poultry, 
with  the  result  of  being  free  from  the  eruption  for  a  long  period 
of  time." 

In  1896  I  brought  the  subject  of  "The  Restriction  of  Meat 
in  the  Treatment  of  Psoriasis"  before  the  Third  International 
Congress  of  Dermatology,3  and  stated  that  "free  indulgence 
in  meat  is  very  apt  to  aggravate  greatly  the  eruption  of 
psoriasis,  whereas  its  restriction,  especially  the  avoidance  of 
beef  and  mutton,  including  extracts,  strong  soups,  etc.,  will 
aid  materially  in  its  removal;  furthermore,  their  continued 
avoidance  will,  I  believe,  contribute  very  greatly  to  a  removal 
of  the  cause  of  the  eruption,  and  assist  in  effecting  a  permanent 
cure  of  the  disease.  ...  I  have  careful  notes  of  many  cases 
where  the  improvement  has  been  most  marked  as  soon  as  the 
stringent  diet  has  been  rigidly  observed,  and  also  notes  con- 
cerning many  patients  who  have  for  several  years  maintained 

1  Trans.  First  Internat.  Cong,  of  Derm,  and  Syph.,  Paris,  1889,  p.  892. 

1  Trans.  Med.  Soc.  State  of  New  York,  1895,  p.  151. 

3  Trans.  Third  Internat.  Cong,  of  Derm.,  London,  1896,  p.  734. 


VOL.  1. — 10 


i46  SIXTH  INTERNATIONAL 

the  same,  with  the  most  manifest  gain  as  regards  a  recurrence 
of  the  eruption." 

Following  up  the  matter  since  that  time,  I  finally  stated 
last  year,1  1906,  at  the  American  Medical  Association,  in  a 
study  of  two  thousand  and  one  hundred  cases  of  psoriasis, 
over  five  hundred  of  which  were  seen  in  private  practice, 
that  "for  many  years  I  have  placed  numerous  psoriasis 
patients  on  a  strictly  vegetarian  diet  with  most  excellent 
results;  and  these  results  are  corroborated  by  the  fact  that 
now  and  again,  when  one  has  broken  through  the  regulations, 
he  or  she  has  reported  with  a  recurrence  of  the  eruption.  I 
make  the  diet  absolutely  vegetarian,  not  even  allowing  eggs 
or  fish,  or  milk  as  a  beverage  with  eating;  and  sometimes  I 
have  even  excluded  coffee  and  tea  with  advantage,"  and  of 
course  all  distilled  and  fermented  drinks. 

The  bearing  of  the  relations  of  an  absolutely  vegetarian 
diet  to  psoriasis  is  understandable  if  one  watches  intelligent 
patients  in  private  practice,  over  a  number  of  years,  with 
careful  and  repeated  note- taking  and  study  of  their  metabolic 
processes;  especially  when  this  latter  is  effected  by  means  of 
frequent  and  complete  quantitative  analysis  of  the  urine  in  all 
possible  aspects.  While  psoriatic  patients  are  commonly 
considered  to  be  in  perfect  health  they  will  constantly  be  found 
to  exhibit  assimilative  disturbances,  especially  along  the  line 
of  faulty  nitrogenous  metabolism  and  diminished  (or  at  times 
greatly  increased)  elimination  of  the  purin  products.  The 
variations  which  may  be  observed  in  the  urine  from  time  to 
time  are  most  striking;  often  varying  in  the  same  patient 
from  a  limpid,  pale  secretion  to  one  of  a  very  high  specific 
gravity.  In  one  instance  this  reached  1041  (no  sugar),  and 
an  acidity,  as  measured  volumetrically,  of  almost  four  times 
the  normal,  with  4.5  per  cent,  of  urea,  over  double  the  normal 
amount. 

Time  does  not  permit  of  our  entering  upon  any  elaborate 
consideration  of  the  physiological  chemistry  of  nitrogenous 
metabolism  as  affected  by  a  purely  vegetable  diet,  especially 
as  this  is  a  practical  paper,  based  on  clinical  facts,  but  very 

ijowrn.  Amer.  Med.  Assn.,  Nov.  17,  1906. 


DERMATOLOGICAL  CONGRESS  147 

brief  mention  may  be  made  of  the  scientific  basis  for  the 
observations. 

It  has  been  shown  that  the  urinary  discharge  of  uric  acid 
does  not  by  any  means  correspond  with  the  amount  of  ordinary 
nitrogenous  food  ingested,  but  that : * 

1.  Uric  acid  is  formed  in  the  body  by  the  disintegration 
of  the  albuminous  substances  of  the  tissues,  especially  of  the 
nuclein  or  nucleins ;  and 

2.  The  excretion  of  uric  acid  becomes  increased  or  dimin- 
ished by  all  factors  (diseases,   medicines,  poisons,  etc.)  which 
give  rise  to  a  more  rapid  or  slower  disintegration  of  the  cellular 
elements  of  the  body,  and  especially  of  the  leucocytes. 

Taylor2  has  demonstrated  that  a  diet  rich  in  nucleins, 
such  as  sweetbread,  more  than  quadrupled  the  excretion 
of  uric  acid,  while  a  heavy  proteid  diet  hardly  increased  it  at  all ; 
and,  moreover,  under  an  exclusively  vegetable  diet  it  was 
still  above  that  found  in  a  normal  mixed  diet,  without  coffee, 
while  the  addition  of  coffee  more  than  doubled  the  output 
of  uric  acid.  Under  a  carbonaceous,  nitrogen-free  diet,  it 
fell  to  seventy-eight  per  cent,  of  normal. 

It  is  not,  therefore,  the  much-discussed  element  of  uric 
acid  which  we  have  to  consider,  but  rather  the  entire  nitro- 
genous metabolism. 

In  the  long  and  carefully  conducted  experiments  of  Taylor, 
he  found  that  under  a  heavy  proteid  diet  the  total  excretion  of 
nitrogen  was  increased  almost  fifty  per  cent.,  and  the  amount  of 
urea  passed  was  also  almost  fifty  per  cent,  above  that  excreted 
under  a  normal  diet ;  while  under  a  vegetable  diet  the  nitrogen 
eliminated  was  reduced  almost  fifty  per  cent.,  as  was  also  the 
urea;  and,  finally,  on  a  purely  carbonaceous,  non-nitrogenous 
diet,  the  nitrogen  output  and  the  urea  were  not  one -quarter 
that  passed  under  normal  diet,  with  or  without  coffee.  The 
latter  was  found  to  more  than  double  the  amount  of  the  purin 
bases,  the  uric  acid  being  also  more  than  doubled. 

It  is  now  pretty  well  established  that  in  health  the  daily 
excretion  of  uric  acid  is  a  fairly  constant  quantity,  depending 
on  the  formation  and  destruction  of  leucocytes;  also  that  it 

1  LEVISON:  Uric  Acid  Diathesis,  etc.,  Engl.  transl.,  London,  1894. 
2 TAYLOR:  Amer.  Journ.  Med.  Sci.,  vol.  cxviii.,  Aug.,  1899,  p.  141. 


1 48  SIXTH  INTERNATIONAL 

varies  in  certain  diseased  states,  and  may  be  increased  by 
anything  which  increases  the  leucocytes  in  the  blood,  while 
in  leucocythemia  it  has  been  found  eight  times  the  normal 
amount.  Foods  containing  large  amounts  of  nuclein  also 
augment  it,  although  ordinary  proteids  do  not,  except  as  they 
increase  the  leucocytes.  In  other  words,  the  production  of 
uric  acid  is  not  much  affected  by  changes  in  diet. 

The  matter  is  very  different,  however,  in  regard  to  other  out- 
puts of  nitrogen,  urea,  etc.,  of  which  it  is  stated  that  seventy- 
three  per  cent,  of  that  ingested  escapes  by  the  kidneys — and 
the  amount  of  nitrogen  in  the  urine  is  found  to  vary  very  defin- 
itely according  to  the  amount  of  nitrogenous  food  taken,  as 
has  been  shown  by  many  observers. 

While  the  studies  which  have  been  made  on  the  urine 
of  patients  with  various  diseases  of  the  skin  do  not  as  yet 
throw  the  light  which  we  could  desire  upon  their  etiology,  we 
know  enough  to  show  that  alterations  in  the  urine,  of  im- 
portant character,  are  constantly  found  in  connection  with 
psoriasis  and  some  other  skin  affections.  Among  hundreds 
of  carefully  made  volumetric  analyses,  I  have  found  in  the 
urine  of  untreated  psoriatic  patients  a  greater  acidity  (two, 
three,  or  even  four  times  the  normal),  a  higher  specific  gravity 
(1030  to  1040  being  not  uncommon),  and  increased  urea  (even 
to  double  the  normal  amount) ,  evidences  of  faulty  nitrogenous 
metabolism,  or  rather  of  an  excessive  intake  of  highly  nitro- 
genized  foods.  As  yet  we  know  very  little  as  to  the  effect  of 
faulty  metabolism  of  carbonaceous  elements  on  the  urine. 

Knowing  the  effects  attributed  to  errors  of  nitrogenous 
metabolism  on  other  structures  of  the  body,  it  is  natural  to 
suppose  that  prolonged  errors  of  this  nature  would  produce 
some  injurious  effect  upon  the  skin;  and  working  on  this 
hypothesis  for  many  years  I  am  convinced  by  clinical  observa- 
tion that  psoriasis  has  its  foundation  in  errors  in  regard  to  the 
passage  of  nitrogenous  elements  into  and  out  of  the  body. 
How  far  back  in  the  system  these  errors  of  nitrogenous  meta- 
bolism extend  cannot  be  stated,  for  the  urine  is  the  only  index 
as  to  how  more  occult  processes  are  carried  out.  Whether 
Haig's  view  as  to  the  retention  of  uric  acid  in  the  system  is 
correct,  or  whether  by  imperfect  oxidation  in  the  tissues 


DERMATOLOGICAL  CONGRESS  149 

of  the  body  other  irritating  compounds  of  nitrogen  are  formed, 
need  not  particularly  concern  us.  The  main  fact  to  recognize 
is  that,  probably  from  erroneous  diet  and  other  causes,  im- 
perfect anabolism  and  catabolism  of  the  proteids  take  place, 
and  in  some  way  either  excite  the  skin  to  wrong  action,  or 
render  it  susceptible  to  other  causes  of  disease. 

It  would  lead  us  still  farther  away  from  the  practical 
purpose  of  this  paper  if  we  attempted  at  all  to  trace  the  causes 
or  methods  by  which  this  faulty  nitrogenous  metabolism 
takes  place — for  indeed  a  good  deal  of  it  is  involved  in  mystery. 
We  know  that  the  life  processes  of  the  body  are  carried  on  by 
oxidation,  and  it  is  quite  understandable  how,  by  a  lowering 
of  the  oxygenating  powers  of  the  system,  imperfect  oxidation 
of  the  proteid  molecules  occurs.  While  this  process  of  oxida- 
tion is  going  on  all  the  time  in  every  part  of  the  organism, 
it  is  of  course  the  blood  which  is  the  active  agent,  both  in 
furnishing  the  requisite  oxygen,  in  various  combinations,  and 
in  carrying  away  in  turn  the  more  or  less  imperfectly  oxidized 
products  of  catabolism.  And  it  must  be  remembered  that  it 
is  from  the  arterial  blood  current  that  the  kidneys  seize  such 
waste  products  as  they  may  be  able  to  handle.  It  is  recog- 
nized also  that  this  blood  current  represents  the  results  of  the 
final  efforts  of  many  vital  organs,  each  contributing  its  quota 
of  result  in  the  interchange  of  external  elements  with  vital 
tissues;  and  also  the  removal  of  effete  or  waste  primary  ele- 
ments, in  various  combinations,  after  they  have  accomplished 
their  purpose  in  the  organism. 

While,  therefore,  I  am  strongly  advocating  an  absolutely 
vegetarian  diet  in  psoriasis,  I  wish  to  emphatically  declare 
that  this  is  only  one  element  in  the  treatment  of  the  disease 
— although  perhaps  the  most  important  one, — and  that  in 
order  to  obtain  the  best  results  there  is  constant  need  of  careful 
medical  supervision,  to  secure  the  proper  working  of  the 
economy  in  all  directions,  and  internal  and  external  medication 
are  called  for  as  necessity  arises. 

I  know  that  with  all  that  has  been  said  in  regard  to  the 
absolute  avoidance  of  meat,  many  are  ready  to  reply  that 
some  years  ago  exactly  the  opposite  plan  of  treatment  was 
advocated,  namely,  an  exclusive  or  almost  exclusive  meat 


1 50  SIXTH  INTERNATIONAL 

diet  in  psoriasis.  This  fact  has  been  so  frequently  alluded 
to  in  text-books  and  current  literature,  that  it  is  necessary 
to  devote  a  few  words  to  it. 

In  1867,  Gustav  Passavant  of  Frankfort,  Germany,  in 
an  open  letter  to  Prof.  F.  V.  Hebra,1  reported  his  own  case 
of  psoriasis  of  twenty-five  years'  standing.  After  trying  for 
many  years  all  known  external  and  internal  treatment,  with 
but  temporary  benefit,  he  states  that  he  was  soon  free  from 
psoriasis,  and  an  accompanying  catarrh,  after  entering  upon 
an  almost  absolute  meat  diet,  including  soups,  pork,  fats, 
cod-liver  oil,  milk,  and  bacon,  and  practically  no  vegetables 
or  bread.  He  advises  against  any  amount  of  vegetables,  wine, 
beer,  coffee,  and  tea ;  also  spices.  He  cites  one  case  of  squamous 
eczema  also  relieved  by  this  treatment. 

There  are  a  number  of  points  in  connection  with  this  brief 
report  which  quite  invalidate  any  importance  which  might 
be  attached  to  it.  First,  Dr.  Passavant  does  not  mention  if 
possibly  he  used  any  treatment,  external  or  internal,  in 
connection  with  the  diet;  then,  he  does  not  state  if  the  im- 
provement in  his  condition  lasted  any  length  of  time,  or  if 
he  had  had  any  return  of  the  eruption,  either  under  the  diet 
or  without  it.  He  also  refers  to  only  one  other  case,  and  that 
of  eczema,  which  was  benefited  by  this  plan  of  treatment. 
Finally,  Hebra,2  to  whom  Dr.  Passavant  addressed  his  open 
letter,  ridicules  the  claim  made,  some  years  after  its  publication, 
and,  as  far  as  I  can  find,  there  has  been  no  subsequent  corrobo- 
ration  in  literature  of  the  correctness  of  the  claims  of  Passa- 
vant that  psoriasis  can  be  cured  by  a  meat  diet.  Surely  if 
there  were  any  truth  in  it,  some  proof  would  be  forthcoming 
in  the  forty  years  which  have  elapsed  since  its  publication. 
On  the  other  hand,  there  are  abundant,  though  brief,  allusions 
in  literature  in  regard  to  the  injurious  effect  of  excessive  meat- 
eating  in  psoriasis. 

More  attention  has  been  given  to  this  matter  than  is 
perhaps  warranted,  but  as  the  statement  of  Passavant  has 
so  often  been  called  up  whenever  the  subject  of  diet  in  pso- 

1  PASSAVANT:     Archiv  fur  Heilkunde,     1867,  p.  251. 

2  HEBRA:      Lehrbuch  der  Hautkrankheiten,   ate  Aufl.,   Bd.   i.,    1874,   p. 
352. 


DERMATOLOGICAL  CONGRESS  151 

riasis  was  referred  to,  it  was  thought  worth  while  to  analyze 
the  subject  and  refute  the  error  once  for  all. 

My  personal  experience  in  regard  to  the  effect  of  diet  on 
psoriasis  extends  over  more  than  twenty  years,  as  has  been 
already  stated. 

In  analyzing  the  notes  of  five  hundred  and  sixty-five  cases 
of  psoriasis  observed  in  private  practice,  I  find  that  about  one- 
half  of  them  were  seen  in  consultation  or  for  but  a  short 
period,  and,  of  course,  many  others  only  at  intervals.  But 
of  those  cases  which  were  observed  long  and  frequently 
enough  to  understand  their  true  condition  and  note  the 
results  of  treatment  over  a  long  period,  I  find  that  there  were 
forty  in  whom  a  more  or  less  vegetarian  diet  was  observed,  and 
a  dozen  or  twenty  who  carried  it  out  strictly,  and  from  whom 
conclusions  can  be  drawn. 

During  the  earlier  years  the  restriction  was  less  severe, 
and  related  mainly  to  the  abstinence  from  beef  and  mutton, 
and  even  these  patients  noticed  a  marked  change  in  the  char- 
acter and  severity  of  the  eruption,  and  often  attributed  a 
relapse  to  indulgence  in  the  prohibited  articles.  But  of  late 
years  I  have  made  the  diet  much  more  strict,  excluding  en- 
tirely all  animal  food,  even  strong  soups,  poultry,  eggs,  and 
fish;  and  1  have  had  a  number  of  patients  for  years  on  an 
absolutely  vegetarian  diet,  only  allowing  butter,  but  no  milk 
as  a  beverage,  and  in  some  cases  I  have  excluded  tea  and 
coffee. 

The  effect  of  this  cutting  off  the  supply  of  animal  nitro- 
genous food  has  been  very  remarkable  and  striking  in  many 
instances  (a  considerable  amount  of  nitrogen  is  still  supplied 
by  certain  vegetables,  as  the  legumes  and  oatmeal) .  Patients 
continually  notice  the  change  in  the  color  and  character  of 
the  eruption,  it  paling  and  becoming  less  scaly,  and  even  en- 
tirely disappearing  in  a  few  weeks,  with  absolutely  no  local 
treatment. 

In  a  number  of  instances  this  diet  has  been  given  to  patients 
who  had  long  been  under  my  care,  even  for  years  previously, 
and  the  patients  and  myself  have  been  well  able  to  judge  of  the 
result  of  this  radical  change  in  their  mode  of  life ;  and  we  have 
watched  with  great  interest  the  often  rapid  improvement 


i S2  SIXTH  INTERNATIONAL 

in  the  eruption,  under  precisely  the  same  treatment  as  before, 
except  that  I  commonly  suspend  local  measures. 

This  treatment  has  been  given  to  patients  at  all  periods 
of  life,  from  9  to  78  years  of  age,  and,  as  has  been  stated,  has 
been  carried  out  with  varying  degrees  of  fidelity.  The  note 
has  been  repeatedly  made  that  when  there  has  been  a  neglect 
of  the  dietary  element,  there  has  been  a  recurrence  of  the 
eruption,  which  again  yielded  rapidly  when  stringent  measures 
were  enforced.  On  the  other  hand,  there  have  been  a  number 
of  patients  who  have  faithfully  pursued  this  plan  of  treatment, 
in  whom  a  long  existing  psoriasis  has  remained  absent,  and 
who,  having  become  quite  accustomed  to  the  diet,  say  that  they 
have  lost  the  desire  for  animal  food  and  will  not  touch  it  again. 
This  plan  of  treatment  has  been  tried  on  some  of  my  patients 
in  the  New  York  Skin  and  Cancer  Hospital,  with  evident 
benefit,  but,  naturally,  it  is  very  difficult  to  carry  out  effec- 
tually such  a  measure  for  a  long  time  in  this  class  of  patients. 
In  one  very  striking  case,  however,  in  a  young  woman  aged 
33,  who  had  been  repeatedly  in  the  Hospital  with  most  ag- 
gravated psoriasis,  the  eruption,  which  covered  almost  the 
entire  body  and  assumed  a  general  exfoliative  condition, 
disappeared  entirely  under  an  absolutely  vegetarian  diet  and 
large  doses  of  nitric  acid,  with  no  local  treatment.  She  re- 
mained afterwards  many  months  in  the  Hospital  free  from 
eruption,  and  when  she  went  out  she  was  seen  occasionally, 
still  faithful  to  treatment  and  free  from  eruption. 

The  oldest  private  patient,  a  man  78  years  of  age,  who  had. 
severe  psoriasis  all  his  life,  and  had  been  some  years  under 
observation,  showed  a  very  remarkable  improvement  as  soon 
as  he  was  persuaded  to  follow  this  diet,  some  five  months 
ago,  and  old  thickened  patches  have  almost  disappeared. 

It  is  not  always  easy  to  convince  patients  of  the  value  of 
this  treatment  and  persuade  them  to  adopt  an  absolute 
vegetarian  diet  with  perfect  strictness  for  a  sufficient  length 
of  time  or  permanently;  and  it  will  often  require  no  little 
insistence  as  well  as  intelligent  aid  on  the  part  of  the  physician 
in  order  to  effect  the  result  desired.  But  after  an  experience 
with  it  for  twenty  years,  I  know  that  it  can  be  effectually 
accomplished,  at  least  in  a  certain  proportion  of  intelligent 


DERMATOLOGICAL  CONGRESS  153 

patients  in  private  practice,  and  I  have  a  number  who  are 
really  enthusiastic  on  the  subject,  and  have  been  so  for  many 
years.  If  from  carelessness  or  necessary  causes,  as  in  travel- 
ling, visiting,  etc.,  the  rules  of  diet  are  transgressed,  and  there 
should  be  some  little  return  of  the  eruption,  this  has  yielded 
to  a  very  strict  observance  of  the  dietary  restrictions,  with 
other  proper  treatment,  better  than  occurs  with  the  latter 
alone. 

Little  need  be  said  in  regard  to  the  general  subject  of  a 
vegetarian  diet,  for  abundant  experience  has  shown  its  value 
under  many  conditions  of  health  and  disease.  The  opinion 
is,  I  believe,  gaining  ground  both  among  the  medical  pro- 
fession and  the  laity,  that  far  too  much  meat  is  eaten  by  those 
who  can  get  it;  and  in  London,  certainly,  the  practice  of 
vegetarianism  is  increasing,  as  is  evidenced  by  the  large  num- 
ber of  well  patronized  restaurants  which  make  this  a  specialty. 
These  are  also  increasing  in  New  York  City.  In  my  ex- 
perience patients  have  felt  remarkably  well  when  this  was 
rightly  directed  and  carried  out,  and  in  numerous  instances 
I  have  found  distinct  and  steady  gain  in  weight  in  the  spare 
and  loss  of  weight  in  the  obese  when  tested  repeatedly  on  the 
same  scales. 

Finally,  I  wish  to  emphasize  the  fact  that  while  an  ab- 
solutely vegetarian  diet  is  advocated  in  psoriasis,  I  believe 
that  it  has  its  limitations,  and  must  be  directed  with  care 
and  intelligence;  but  that  in  proper  cases  it  can  control  the 
eruption  and  prevent  its  recurrence  I  am  confident.  I  wish 
also  again  to  make  clear  that  patients  with  this  eruption  at 
times  will  require,  in  addition,  the  most  varied  treatment, 
internal  and  external,  in  order  to  accomplish  the  quickest 
and  best  results.  How  internal  remedies  act  cannot  yet  be 
fully  stated,  but  in  the  light  of  our  present  study  they  probably 
have  their  action  in  improving  the  metabolism  of  nitrogenous 
substances. 

Discussion 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  had  listened 
with  great  interest  to  Dr.  Bulkley's  paper,  which  illustrated  what 
different  conclusions  two  observers  of  about  equal  age  and  ex- 
perience could  arrive  at  in  regard  to  a  disease  which  was  extremely 


i54  SIXTH  INTERNATIONAL 

common  and  which  so  frequently  came  under  the  observation  of 
both.  He  was  disappointed  that  Dr.  Bulkley  had  not  distin- 
guished between  the  cases  of  psoriasis  that  began  in  early  life  and 
those  that  began  after  middle  life.  In  cases  of  psoriasis  occurring 
after  middle  life  in  patients  with  an  undoubted  gouty  tendency, 
the  proper  restriction  of  the  nitrogenous  diet  is  certainly  indicated, 
but  when  we  came  to  include  cases  of  all  ages,  then  Dr.  Crocker 
said  he  had  to  join  issue  with  the  reader  of  the  paper.  He  had 
seen  psoriasis  in  vegetarians  and  in  butchers,  and  he  had  arrived 
at  the  conclusion  that  diet  had  very  little  influence  upon  the  course 
of  the  disease.  He  believed,  however,  that  anything  approaching 
an  excessive  use  of  alcohol  had  an  aggravating  effect  on  the  eruption. 
The  speaker  said  he  began  his  work  as  a  dermatologist  as  a  pupil 
of  Dr.  Tilbury  Fox,  with  whom  errors  of  diet  were  a  fundamental 
principle,  and  he  did  not  break  away  from  the  influence  of  that 
teaching  until  clinical  facts  forced  him  to  do  so.  His  conclusions 
in  regard  to  the  influence  of  diet  upon  psoriasis  were  totally  unlike 
those  of  Dr.  Bulkley.  He  recalled  the  case  of  a  girl  of  13, 
the  daughter  of  a  medical  man,  with  well-marked  psoriasis,  whose 
father  had  assured  him  that  she  was  a  natural  vegetarian,  and 
that  she  had  never  eaten  a  piece  of  meat  of  any  size  in  her  life.  A 
study  of  the  age  at  which  psoriasis  first  made  its  appearance  would 
show  that  fully  two-thirds  of  the  cases  had  their  onset  before  the 
age  of  30 — that  is,  during  a  stage  of  life  when  errors  in  metabolism 
were  comparatively  few. 

Dr.  Crocker  also  called  attention  to  the  fact  that  in  a  very  large 
proportion  of  cases  of  psoriasis  the  eruption  began  locally  in  one 
or  two  regions  of  the  body,  where  it  remained  for  weeks,  months, 
and  even  years.  Then,  under  circumstances  which  varied  in 
different  cases,  the  disease  began  to  generalize  and  become  sym- 
metrical, and  from  that  time  on  remained  symmetrical.  He 
believed  that  if  these  initial  lesions  were  vigorously  treated,  we 
might  hope  to  cure  the  disease,  but  even  if  we  failed  in  that,  we 
could  often  succeed  in  wearing  it  down  to  very  small  proportions. 
The  speaker  said  he  had  lived  long  enough  to  see  cases  of  a  very 
diffuse  character,  after  having  been  under  his  observation  for 
many  years,  gradually  improve  under  steady,  persevering  treat- 
ment, sometimes  medicinal  and  sometimes  local,  but  always  largely 
local,  until  finally  the  disease  was  reduced  to  very  trivial  propor- 
tions, and  was,  so  to  speak,  driven  into  a  corner.  In  some  of  his 
psoriatic  patients  who  had  remained  faithful,  and  whom  he  called 
his  "hardy  annuals,"  the  disease  had  been  practically  worn  out. 


DERMATOLOGICAL  CONGRESS  155 

He  was  strongly  inclined  to  believe  that  psoriasis  was  microbic 
in  the  beginning  and  that  it  gets  into  the  circulation,  with  periods 
of  dormancy  and  activity.  He  regarded  it  as  a  self-multiplying 
disease,  and  believed  that  during  every  attack  persevering  treat- 
ment should  be  continued  until  every  speck  was  removed. 

Dr.  Crocker  said  that  if  he  got  hold  of  a  gouty  patient  with 
psoriasis,  then  he  would  regulate  the  diet  accordingly.  The  same 
was  true  of  dyspeptic  patients,  but  as  for  the  effect  of  diet  upon 
psoriasis,  as  such,  he  did  not  regard  it  as  an  important  factor  in 
the  etiology  of  the  disease. 

PROP.  THEODOR  VEIEL,  Cannstatt,  Wurttemberg,  erklarte,  dass 
er  speziell  auf  die  Empfehlungen  Dr.  Bulkley's  hin  bei  seinen 
Patienten  vegetarianische  Kost  empfohlen  habe,  dass  er  aber 
im  Erfolg  nicht  so  gliicklich  gewesen  wie  Dr.  Bulkley.  Er  konne 
sich  das  nur  dadurch  erklaren,  dass  Gicht  in  Siiddeutschland  viel 
seltener  sei  als  in  anderen  Landern. 

DR.  BULKLEY,  in  closing  the  discussion,  said  he  was  inclined 
to  believe  that  psoriasis  was  a  parasitic  disease;  that  there  was  a 
micro-organism  somewhere  which  developed  at  times,  for  reasons 
of  which  we  were  still  ignorant,  but  primarily  on  account  of  faulty 
nitrogenous  metabolism.  The  speaker  said  he  did  not  see  many 
cases  of  psoriasis  associated  with  well-marked  gout  or  rheumatism. 
There  were  a  certain  number  of  such,  but  not  many.  If  one  could 
by  treatment  correct  the  faulty  metabolism  due  to  the  excess  of 
nitrogenous  elements,  or  prevent  their  accumulation,  the  same 
object  would  be  attained,  but  he  thought  a  simpler  method  was  to 
cut  off  the  supply. 

Dr.  Bulkley  said  he  was  fully  in  accord  with  Dr.  Crocker  that 
this  method  of  treatment  was  not  applicable  to  every  case.  In 
every  case,  also,  we  needed  other  treatment  as  well.  It  would  be 
foolish  to  simply  limit  the  treatment  to  a  vegetarian  diet.  These 
patients  must  be  watched  very  carefully.  The  urinary  output 
must  be  investigated;  the  patients  must  have  proper  air,  etc.,  but 
the  main  factor  was  to  cut  off  that  kind  of  food  which  produced 
this  condition.  In  certain  cases  he  had  continued  the  diet  for 
over  ten  years. 

End  of  First  Day 


SECOND  DAY,  TUESDAY,  SEPTEMBER  IOTH 

CLINICAL  DEMONSTRATION  OF  CASES,  9-11  A.M. 

A  Case  of  Acanthosis  Nigricans 
PRESENTED  BY  DR.  L.  DUNCAN  BULKLEY,  OF  NEW  YORK 

E.  L.,  age  seven  years,  presented  herself  at  the  dispensary 
for  treatment  Aug.  23,  1907.  No  family  or  previous  personal 
history  could  be  obtained  beyond  the  fact  that  the  lesions 
present  dated  back  four  years.  The  child  exhibited  an 
ichthyotic-like  condition  of  areas  of  the  skin.  Between  them 
the  cutis  was  almost  normal,  the  areas  themselves  being  pretty 
generally  distributed  over  the  whole  body.  Their  margins 
were  sharply  defined  with  a  gyrate  configuration,  being  in 
some  places  confluent  and  in  other  places  constituting  separate 
islands  of  layers  of  smaller  size.  The  condition  of  the  separate 
patches  might  be  described  as  a  verrucous-like  hypertrophy 
of  the  superficial  layers  of  the  integument,  presenting  the 
dry  rough  scaly  sensation  of  ichthyosis.  The  color  of  the 
patches  varied  from  light  cafe  au  lait  to  a  dark  brown.  The 
most  marked  discoloration  was  in  the  axillary  patches.  In 
general,  the  color  was  darker  in  the  portions  of  the  body 
most  affected.  These  were  the  axillae,  the  outer  and  inner 
surface  of  the  upper  arms,  the  extensor  surface  of  the  fore- 
arms, the  outer  surface  of  the  pelvis  and  hips,  and  the  outer 
surface  of  the  thighs  and  lower  legs. 

A  portion  of  one  of  the  affected  patches  near  the  axilla 
was  removed  for  examination.  Section  showed  a  general 
lengthening  of  the  papillae,  some  increase  in  their  height  and 
a  marked  hypertrophy  of  the  stratum  corneum.  The  dry 
flattened  scales  of  the  latter  remained  adherent  to  the  under- 
lying stratum  lucidum  so  as  to  form  a  very  thick  layer.  The 
stratum  granulosum  presented  a  distinct  pigmentation  so 
that  the  color  of  the  lesions  could  be  seen  to  be  definitely  due 
to  a  deposit  of  pigment  granules  in  this  layer.  The  rete 

156 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS         157 

Malpighii  and  the  corium  presented  no  particular  deviation 
from  the  normal. 

DR.  HENRY  W.  STELWAGON,  of  Philadelphia,  said  he  was  in- 
clined to  disagree  with  Dr.  Bulkley's  diagnosis  of  acanthosis  ni- 
gricans.  From  the  age  of  the  patient,  the  absence  of  involvement 
of  the  mucous  membranes,  and  the  lack  of  any  evidence  of  internal 
or  visceral  disease  he  was  rather  inclined  to  look  upon  it  as  a  case 
of  ichthyosis.  As  he  recalled  it,  acanthosis  usually  occurred  in 
middle  or  advanced  life.  He  would,  therefore,  make  the  diagnosis 
of  ichthyosis  hystrix. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wiirttemberg,  said  he 
had  shown  at  Heidelberg  a  case  quite  similar  to  that  of  Dr.  Bulk- 
ley's,  but  the  lesions  in  that  case  were  confined  to  one  half  of  the 
body.  The  case  was  no  doubt  one  of  naevus,  and  it  was  a  well- 
known  fact  that  naevi  very  often  appeared  after  birth.  The 
speaker  said  that  he  was  inclined  to  regard  Dr.  Bulkley's  case  as 
one  of  naevus  rather  than  acanthosis  nigricans. 

A  Case  of  Rhinoscleroma  Treated  with  the  X-Rays 
PRESENTED  BY  DR.  SAMUEL  STERN,  OF  NEW  YORK 
The  patient  was  treated  by  him  at  the  clinic  of  Dr.  Lust- 
garten  at  the  Mt.  Sinai  Hospital.  She  was  a  Russian,  fifty-three 
years  old.  The  lesion  first  began  fifteen  years  ago.  X-ray 
treatment  was  begun  on  June  i,  1906.  At  that  time  her  nose 
was  very  much  enlarged,  there  were  large  extranasal  tumors  on 
both  sides  of  the  nostrils  reaching  down  almost  to  the  upper  lip. 
The  nose  was  of  a  hard  ivory  consistency  and  both  nostrils 
were  occluded.  She  had  a  number  of  operations  without  any 
result.  Up  to  date  the  patient  had  fifty  treatments  beginning 
with  three  times  a  week,  five  minutes'  duration  each  with 
a  fairly  high  vacuum  tube,  then  gradually  diminished  to  twice 
and  once  a  week.  Improvement  was  very  rapid,  beginning 
after  the  first  few  treatments,  the  patient  being  practically 
well  when  shown. 

A  Case  of  Blastomycosis  in  a  Negro 

PRESENTED   BY   DR.    GEORGE   HENRY  Fox,   OF   NEW  YORK 
Man  twenty-nine  years  old ;  single ;  U.  S. ;  laborer. 
Mother  and  brother  died  of  consumption.     Patient  had 
always  lived  in  Virginia  till  five  years  ago  when  he  came  to 


i58  SIXTH  INTERNATIONAL 

New  York.  Up  to  the  beginning  of  present  illness,  he  had 
always  been  well.  First  noticed  a  "pimple"  on  buttock 
which  had  become  a  scaly  patch  the  size  of  a  dime  within 
a  month.  A  year  and  a  half  later  the  lesion  had  attained  the 
size  of  a  dollar  and  was  an  open  sore.  It  remained  stationary 
till  he  came  to  New  York.  He  was  treated  at  Presbyterian 
Hospital  by  pills  and  drops  for  six  months  and  given  mixed 
treatment  at  the  Skin  and  Cancer  Hospital.  Improvement 
but  no  cure  resulted. 

Three  months  ago  section  made  by  Dr.  Jagle  showed 
typical  histological  structure  of  blastomycosis  and  the  pres- 
ence of  blastomycetes  in  section.  The  lesion  then  presented 
a  large  horseshoe-shaped  ulceration  with  vegetating  borders 
and  purulent  discharge.  Blastomycetes  were  found  very 
sparingly  in  hanging  drop  preparations.  Plate  cultures  were 
all  contaminated.  Subcutaneous  inoculations  of  guinea  pigs 
produced  abscesses  containing  staphylococci  only;  no  blas- 
tomycetes. X-ray  treatment  for  the  past  four  months  had 
produced  great  improvement.  A  portion  of  the  lesion  for  pur- 
poses of  future  examination  and  demonstration  at  the  Congress 
was  not  rayed.  The  remaining  area  showed  a  slowly  healing, 
bean-shaped  shallow  ulcer,  four  inches  in  length. 

A  Case  of  Urticaria  Pigmentosa  of  Thirty-three  Years'  Duration 

PRESENTED  BY   DR.  PRINCE  A.  MORROW,  OF  NEW  YORK 

The  patient,  now  thirty-three  years  of  age,  came  under 
Dr.  Morrow's  observation  in  July,  1876.  He  was  then  nearly 
two  years  of  age  and  the  eruption  had  existed  since  early 
infancy. 

This  was  the  first  case  of  urticaria  pigmentosa  recognized 
in  this  country  and  the  fourth  recorded  in  medical  literature. 
Its  interest  lay  in  the  prolonged  persistence  of  eruption  and 
its  evolutionary  mode,  as  shown  in  the  various  modifications 
in  the  color,  configuration,  and  general  objective  characters 
of  the  lesions,  which  were  detailed  in  the  report  of  the  case 
(Archives  of  Dermatology,  1879,  and  Journ.  Cutaneous  and 
Genito-Urinary  Diseases,  Nov.,  1895). 

When  the  case  first  came  under  observation  the  eruption 
consisted  of  variously  sized  circular  pigmented  spots  of  a 


DERMATOLOGICAL  CONGRESS  159 

yellowish  or  brownish  tint,  generally  distributed,  but  most 
abundant  over  the  back  and  flexures  of  the  joints,  and  inter- 
spersed with  larger  protuberant  lesions,  nodular  in  character. 
Within  the  next  year  or  two  there  was  an  obvious  increase 
in  the  number  of  the  lesions,  until  the  eruption  became  prac- 
tically universal.  With  the  exception  of  a  limited  area  of 
healthy  skin  at  the  root  of  the  nose  and  over  the  malar  prom- 
inences, the  eruption  covered  the  entire  surface  of  the  body; 
the  palms  and  soles,  and  even  the  eyelids  were  profusely 
studded;  the  mucous  membrane  of  the  palate  and  fauces  was 
also  involved. 

In  March,  1895,  the  period  of  the  second  report,  it  was 
found  that  marked  retrogressive  changes  had  taken  place  in 
the  eruption.  The  pigmented  spots  had  faded  from  the  face, 
hands  and  feet,  the  back  of  the  scalp,  the  mucous  surfaces, 
and  the  more  exposed  parts  of  the  body  generally.  The 
nodular  lesions  had  entirely  disappeared,  and  most  of  the 
spots — especially  upon  the  back  and  sides  of  the  chest — had 
lost  their  circular  configuration  and  become  elliptical  or 
elongated  in  shape. 

The  patient  had  always  been  the  subject  of  factitious 
urticaria,  exhibiting  most  characteristically  the  phenomenon 
of  dermographism.  The  pigmented  lesions  exhibited  a  much 
more  marked  susceptibility  to  this  urticarial  reaction  than  the 
healthy  intervening  skin.  His  general  health  had  not  been 
appreciably  affected  by  the  cutaneous  trouble. 

A  Case  of  Multiple  Idiopathic  Hemorrhagic  Sarcoma  (Kaposi) 

(FROM  DR.  LUSTGARTEN'S  CLINIC.) 
PRESENTED  BY  DR.  ADELBERT  B.  BERK,  OF  NEW  YORK 
N.  F.,  fifty-eight  years  old,  married,  had  seven  children, 
all  living  and  well.  Patient  himself  was  in  good  health,  when, 
while  still  in  Russia,  fifteen  years  ago,  the  present  skin 
affection  began  with  swelling  of  both  feet,  followed  by  suc- 
cessive eruptions  of  various  sized  more  or  less  prominent, 
bluish-red,  semi-hard,  irregularly  disseminated  nodules.  Grad- 
ually the  process  advanced  upward  to  the  inguinal  region  on 
both  limbs,  which  became  diffusely  affected  and  increased 
in  size  to  shapeless,  rigid,  elephantiasis-like  extremities,  with 


160  SIXTH  INTERNATIONAL 

greatly  thickened  integument,  subject  to  attacks  of  dermatitis 
and  eczema.  Walking  was  difficult.  The  loins,  vola  manus, 
and  lower  arms  also  participated  in  the  process.  The  suc- 
cessive eruptions  were  associated  with  intense  lancinating 
deep  pain.  Under  prolonged  arsenic  injections  and  also  perse- 
vering X-Ray  treatment,  the  condition  improved  perceptibly. 

DR.  GEORGE  HENRY  Fox,  of  New  York,  said  the  case  shown  by 
Dr.  Berk  had  been  presented  by  him  at  a  meeting  of  the  American 
Dermatological  Association  under  the  same  diagnosis  of  pigmented 
sarcoma,  but  at  that  time,  which  was  two  or  three  years  ago,  there 
was  a  resistant  eczema  of  one  leg  which  had  since  improved. 

A  Case  of  Mycosis  Fungoides 

PRESENTED  BY  DR.  SAMUEL  STERN,  OF  NEW  YORK 
The  patient  was  treated  by  him  at  the  clinic  of  Dr.  Lust- 
garten  at  the  Mt.  Sinai  Hospital.  He  was  a  Russian,  forty- 
four  years  old.  The  lesions  originally  began  nine  years  ago, 
and  were  scattered  over  the  entire  body,  including  the  face. 
He  had  lost  forty  pounds  and  was  in  bad  physical  condition. 
About  one  hundred  arsenic  injections  had  produced  no  effect. 
X-ray  treatment  was  begun  in  November,  1903,  at  the  rate 
of  three  times  a  week  on  an  average  of  twenty  minutes'  dura- 
tion each.  The  subjective  symptoms  yielded  very  promptly. 
Treatment  had  been  continued  up  to  date.  The  patient  was 
perfectly  well  while  under  treatment  but  lesions  promptly 
recurred  if  it  was  discontinued  for  a  while.  New  ones  yielded 
readily,  and  it  appeared  as  if  the  patient  could  be  kept  well 
indefinitely  with  the  X-ray.  He  had  had  in  all  probably  four 
hundred  exposures. 

A  Case  for  Diagnosis 

PRESENTED  BY  DR.  EDWARD  P.  McGAvocK,  OF  NEW  YORK 
Mr.  W. ,  aged  fifty-seven.     Previous  history  negative. 
In   1898  a  small  hard  painful  swelling  formed  behind  the 
left  ear,  was  incised  and  exuded  a  small  quantity  of  pus. 
Shortly  after  a  slowly  spreading,  ulcerating  process  developed, 
with  raised  reddish  borders,   scaling  and  numerous  miliary 
abscesses;  at  times  intensely  pruritic.     It  healed  leaving  in  its 
path  a  smooth  glistening  superficial  scar,  devoid  of  hair  and 
showing  no  tendency  to  return  in  old  site. 


DERMATOLOGICAL  CONGRESS  161 

In  1902  the  greater  part  of  the  left  side  of  head  was  in- 
volved and  a  portion  of  side  of  neck.  The  diagnosis  of  blas- 
tomycosis  was  suggested,  and  he  was  treated  with  a  50% 
alcoholic  solution  of  resorcin  externally  and  iodoform  pills 
internally.  After  five  months  the  pills  were  discontinued 
and  a  saturated  solution  of  potassium  iodide  substituted  in 
increasing  doses  up  to  60  m.  t.  i.  d.  In  two  months  all  had 
healed  except  an  area  the  size  of  a  dime  over  the  larynx.  This 
remained  quiescent  about  two  months,  then  became  active, 
the  disease  advancing  along  the  neck  below  and  behind  the 
right  ear  and  down  to  the  sternal  notch.  During  the  second 
exacerbation  the  treatment  was  vigorously  continued  without 
effect. 

X-rays  were  then  applied,  medium  tubes,  two  to  five 
minutes,  four  to  eight  inches.  He  had  fourteen  exposures 
covering  a  period  of  three  months,  at  the  end  of  which  time 
only  a  trace  of  the  affection  was  left.  Three  weeks  later  a 
severe  dermatitis  developed.  The  disease  then  reappeared  at 
several  points  and  most  pronouncedly  where  the  dermatitis 
was  greatest.  Numerous  cultures  were  made  on  glucose, 
glycerine,  and  plain  agar  and  bouillon,  but  only  staphylococci 
and  streptococci  were  obtained.  Smears  of  pus  likewise 
only  revealed  Gram  positive  cocci. 

Smears  and  tissue  both  were  examined  for  blastomycetes 
but  without  result. 

Sections  of  the  tissue  showed  epidermic  hyperplasia  with 
small  abscesses.  In  the  corium  there  was  a  diffuse  infiltra- 
tion of  lymphocytes,  polynuclear  leucocytes,  and  plasma 
cells.  No  giant  cells  were  present. 

PROF.  ERICH  HOFFMAN,  of  Berlin,  referred  to  a  case  which  was 
somewhat  similar  to  the  one  shown  by  Dr.  McGavock,  but  the 
scar  involved  both  sides  of  the  head  and  was  symmetrical.  The 
case  was  regarded  as  one  of  ulerythema  sycosiforme  (Unna). 

A  Case  of  Adenoma  Sebaceum 

PRESENTED  BY  DR.  CHARLES  T.  DADE,  OF  NEW  YORK 
A  young  girl  aged  fourteen,  imbecile  and  an  epileptic, 
remarkably   well   developed   physically.     Face   over   middle 
two-thirds  presented  the  characteristic  crimson  nodules  with 


162  SIXTH  INTERNATIONAL 

telangiectic  vessels  on  and  around  them — more  marked 
along  the  naso-labial  folds.  Lesions  appeared  shortly  after 
birth  and  have  gradually  increased  in  number  and  size. 
Over  scalp,  neck,  and  upper  part  of  body  were  the  asso- 
ciated small  fibromata,  warty  growths,  and  pigmentation. 
One  of  the  fibromata  on  the  scalp  was  the  size  of  a  five- 
cent  piece.  The  texture  of  her  skin  was  coarse  and  greasy. 

A  Case  of  Endarteritis  Luetica 

(FROM  DR.   LUSTGARTEN'S  CLINIC) 

PRESENTED  BY  DR.  ADELBERT  B.  BERK,  OF  NEW  YORK 

A.  K.,  thirty  years  old,  married  six  years,  two  children. 
Parents,  brothers,  and  sisters  living.  No  sickness  till  three 
years  ago,  when  the  middle  finger  on  his  right  hand  gave 
him  violent  pain,  getting  worse  on  exposure  to  cold  weather. 
In  about  two  months  a  gangrenous  sore  developed,  with  no 
tendency  to  healing;  the  end  phalanx  was  enucleated  after 
six  months'  unsuccessful  treatment.  The  following  winter 
the  middle  ringer  of  the  left  hand  became  sore  and  at  the 
same  time  the  fourth  finger  on  the  right  hand  became  livid 
and  cold.  He  then  entered  the  hospital  for  three  weeks, 
received  specific  treatment,  and  improved  perceptibly.  Last 
winter  the  toes  on  his  left  foot  became  swollen,  bluish,  cold, 
and  painful,  and  gradually  gangrene  of  four  toes  developed. 
He  was  taken  to  some  hospital  and  amputation  of  the  lower 
third  of  the  leg  was  performed.  The  flap  became  gangrenous 
and  broke  down.  Healing  took  place  by  slow  granulations. 

The  pulse  in  both  radials  at  time  of  presentation  could 
hardly  be  felt,  though  after  the  first  specific  treatment  the 
stagnant  circulation  in  the  fingers  was  fully  restored. 

A  Case  of  Pityriasis  Rubra  of  Hebra 

PRESENTED  BY  DR.  GEORGE  HENRY  Fox,  OF  NEW  YORK 
Girl,  twelve  years  old;  school;  born  in  Scotland. 
She  had  scarlet  fever  when  three  years  old.     Seven  years 
ago  she  first  noticed  that  her  palms  were  becoming  rough. 
Later  an  eruption  appeared  upon  the  forehead,  face,  and  rest 
of  the  body.     It  lasted  about  eight  months  and  disappeared 
entirely.     Two  years  later  the  eruption  appeared  again  and 
within  one  month  had  become  universal.     Since  then  there 


DERMATOLOGICAL  CONGRESS  163 

had  been  a  marked  improvement  on  several  occasions,  al- 
though the  eruption  has  never  disappeared  completely.  Her 
general  health  was  fair. 

The  skin  was  not  thickened  but  covered  mostly  with 
flakes  of  epidermis  adherent  in  the  central  portion. 

PROP.  ERICH  HOFFMANN,  of  Berlin,  said  the  patient  presented 
by  Dr.  Fox  showed  distinct  areas  of  exfoliation,  and  he  was  in- 
clined to  regard  the  case  as  one  of  dermatitis  secondary  to  psoriasis 
rather  than  one  of  pityriasis  rubra. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  regarded  the 
case  shown  by  Dr.  Fox  as  one  of  exfoliative  dermatitis;  whether 
secondary  to  psoriasis  or  not  depended  on  the  history.  He  did 
not  think  that  the  duration  of  the  eruption  or  the  age  of  the  patient 
negatived  that  diagnosis. 

DR.  RALPH  WILLIAMS,  of  Los  Angeles,  said  that  in  two  cases 
of  pityriasis  rubra  that  had  come  under  his  observation  the  pa- 
tients complained  of  extreme  cold,  and  the  skin  had  a  more  purplish 
hue  than  in  the  case  shown  by  Dr.  Fox.  The  child  shown  to-day 
stated  that  she  formerly  suffered  from  cold,  but  not  now.  She 
gave  no  history  of  having  had  any  of  the  typical  lesions  of  psoriasis. 

DR.  EDWARD  H.  SHIELDS,  of  Cincinnati,  said  that  he  had  seen 
several  cases  of  pityriasis  rubra;  all  had  the  fine  scale  which  is 
typical  of  this  disease;  the  skin  was  pale,  thin,  and  quite  tight. 
There  was  no  evidence  of  inflammation  as  seen  in  this  case.  During 
the  time  one  of  the  patients  was  under  his  care,  he  always  com- 
plained of  being  cold,  even  in  warm  weather.  The  case  ended 
fatally  after  being  under  treatment  for  a  year. 

A  Case  of  Pityriasis  Rubra  Pilaris 
(FROM  DR.  LUSTGARTEN'S  CLINIC) 
PRESENTED  BY  DR.  ADELBERT  B.  BERK,  OF  NEW  YORK 
B.  L.,  bom  in  U.  S.  1900. 

Family  history  negative.  Child  had  had  measles  and 
pertussis  when  three  years  old.  Present  illness  began  at 
nine  months  of  age  as  a  dry,  gooseflesh-like  roughening 
of  the  slightly  reddened  skin  on  the  extensor  surfaces  of 
extremities.  No  subjective  symptoms  for  two  years,  when 
the  affected  areas  extended  and  were  accompanied  by  itching, 


1 64  SIXTH  INTERNATIONAL 

chilliness,  and  dryness  even  in  the  summer.  Anaemia  and 
diminished  liveliness  followed  this.  Present  state:  Physical 
examination  negative  except  cutaneous  lesions.  Blood  and 
urine  normal.  The  cheeks,  forehead,  ears,  and  neck  showed 
reddish-yellow,  irregularly  shaped  patches  of  closely  aggre- 
gated, dry,  minute,  and  elevated  papules  with  a  bran-like 
scaly  substance  of  a  yellowish  hue.  The  follicles  of  the  skin 
were  rather  enlarged  and  plugged  by  scaly  cones.  On  both 
arms  and  legs,  especially  on  the  dorsal  surfaces  of  the  pha- 
langes, were  partly  discrete,  partly  confluent,  yellowish  white 
areas  raised  above  the  level  of  the  integument  with  enclosures 
of  normal  skin  here  and  there.  The  follicular  horny  plugs 
were  especially  marked  under  the  knee-caps  and  over  the 
fingers.  Hair  and  nails  were  normal.  Treatment  consisted 
of  injections  of  three  minims  of  a  ten  per  cent,  atoxyl  solution 
and  externally  one-half  per  cent,  salicyl.  of  lanolin,  under 
which  patient  was  improving. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  referred 
to  a  case  similar  to  the  one  shown  by  Dr.  Berk  which  he  had  seen 
at  Stuttgart.  In  that  instance,  the  disease  began  in  childhood. 
He  regarded  the  case  as  one  of  ichthyosis  papillaris.  The  con- 
dition was  incurable,  so  far  as  his  experience  went. 

PROF.  ERICH  HOFFMANN,  of  Berlin,  thought  the  case  shown 
by  Dr.  Berk  was  one  of  psoriasis  of  the  follicular  type. 

A  Case  of  Lenticular  Carcinoma  and  Carcinomatous  Lymphangitis 
PRESENTED  BY  DR.  J.  A.  FORDYCE,  OF  NEW  YORK 

Mrs.  C.,  aged  twenty-eight,  married,  four  children.  Pre- 
vious history :  For  nine  years  she  had  had  trouble  with  her 
right  breast,  following  an  abscess  after  the  birth  of  her  first 
child.  Small  cutaneous  lesions  developed  nine  months  ago, 
first  around  nipple  and  gradually  spreading. 

When  shown,  the  patient  was  in  the  eighth  month  of 
gestation.  She  had  a  hard  tumor  of  both  breasts,  the  nipple 
of  the  right  one  being  markedly  retracted  and  of  the  left 
only  slightly.  Multiple  lenticular  nodules,  pin-head  to  split- 
pea  in  size,  were  situated  in  the  skin  covering  both  mammae: 
some  were  eroded  and  discharging  a  serous  fluid,  others 
were  red  and  dry.  Under  the  breast  they  were  con- 


DERMATOLOGICAL  CONGRESS  165 

fluent,  forming  moist  patches.  There  were  also  large  ery- 
thematous  areas  over  the  right  side  of  trunk  and  upper  part 
of  right  arm  with  a  distinct  unilateral  distribution — a  car- 
cinomatous  lymphangitis.  In  places  there  was  a  slight 
infiltration. 

Microscopical   examination   confirmed  the  diagnosis. 

A  Case  of  Luetic  Infection  with  Symmetrical  Cutaneous  Atrophy 
PRESENTED  BY  DR.  J.  A.  FORDYCE,  OF  NEW  YORK 

E.  E.,  aged  forty-three,  Swedish.  The  affection  began  in 
1893  on  the  back  of  the  left  hand  with  persistent  redness. 
Later  on  the  elbows,  ankles,  and  knees  became  affected  in  the 
same  manner.  Bullae  formed,  ruptured,  and  discharged  a 
serous  fluid.  Pain  and  swelling  would  remain  for  a  few 
days  and  then  disappear  for  two  or  three  weeks.  The  pain 
was  more  pronounced  along  the  anterior  surfaces  of  the  tibiae. 
In  addition,  there  were  patches  of  atrophic  skin  surrounded 
by  zones  of  pigmentation  and  dilated  capillaries.  The  eruption 
was  absolutely  symmetrical. 

In  1898  she  suffered  from  a  left-sided  hemiplegia  and 
slowly  regained  the  use  of  her  arm  and  leg.  A  diagnosis  of 
syphilitic  brain  lesion  was  made.  Some  months  later  a 
typical  serpiginous  syphilide  developed  on  the  inner  aspect 
of  the  right  forearm,  which  yielded  slowly  under  the  use  of 
mercury  and  iodides  for  more  than  a  year.  At  the  end  of 
that  time  it  was  noted  that  the  atrophy  had  not  progressed 
beyond  the  regions  first  invaded  and  she  was  in  much  better 
general  health. 

Microscopically,  the  lesion  was  found  to  be  an  inflammatory 
one  primarily,  with  endarteritis  and  thrombosis  of  the  vessels, 
the  changes  in  the  latter  being  probably  the  original  seat  of 
the  trouble. 

A  Case  of  Multiple  Telangiectases,  with  Spontaneous  Hemorrhage ; 

Bleeding  Stigmata. 

PRESENTED  BY  DR.  WILLIAM  S.  GOTTHEIL,  OF  NEW  YORK 

Harry  D.,   forty,   Russian,   first   seen  August    12,    1907. 

Complained  of  periodic,  spontaneous  hemorrhages  from  the 

nose,  tongue,  and  lips,  which  he  had  had  as  long  as  he  could 

remember,  and  for  which  he  had  been  under  treatment  both 


i66  SIXTH  INTERNATIONAL 

in  Europe  and  here.  He  was  not  a  hemophilia  in  the  ordinary 
sense  of  that  term;  cuts  did  not  bleed  excessively  and  healed 
readily;  had  had  a  tooth  extracted  two  weeks  before  without 
much  bleeding.  He  stated  that  his  bleeding  was  of  two  dis- 
tinct kinds;  from  the  nose  it  occurred  as  a  slow  trickling, 
lasting  perhaps  ten  or  fifteen  minutes ;  from  the  visible  lesions 
of  the  tongue  and  lips,  to  be  described  later,  it  came  as  a  sud- 
den projectile  spurt,  sometimes  reaching  out  a  foot  or  two  if  on 
the  lips  or  if  his  mouth  was  open,  and  stopping  spontaneously 
in  two  or  three  minutes.  He  was  perfectly  sure  that  these 
hemorrhages  had  no  relation  to  injuries,  or  to  mastication, 
picking  the  teeth  or  nose,  etc.  The  hemorrhages  came  on 
at  entirely  irregular  intervals;  there  was  sometimes  only 
one  a  week,  and  sometimes  he  had  several  in  one  day. 
Latterly  they  had  been  getting  more  frequent. 

Examination — Nasal  mucosa,  and  that  of  the  pharynx  and 
gums  slightly  congested  only.  Tongue  and  lips  showed  a 
number  of  minute,  bright  red  spots,  pin-head  and  less  in  size, 
looking  like  small  angiomata.  These,  the  patient  stated,  were 
permanent;  and  they  had  certainly  not  changed  from  the 
time  of  his  first  examination  to  that  of  presentation. 

Family  history  was  of  interest,  though  he  did  not  know 
the  facts  as  to  his  grandparents  on  either  side,  or  as  much  as 
might  be  expected  of  his  more  immediate  relatives. 

Parents — Father  was  not  a  bleeder.  Mother  had  "spots" 
on  lips  and  was  said  to  have  died  of  hemorrhage  twenty-seven 
years  ago. 

Brothers — Had  four,  all  living;  three,  aged  fifty-five, 
fifty,  and  forty-eight,  bleeders;  one,  aged  forty,  was  immune. 
All  had  hemorrhages  from  the  nose,  but  no  "spots"  in  or 
bleeding  from  the  mouth. 

Sisters — Two;  one  was  a  bleeder,  like  the  brothers. 

Children — Five;  two  were  bleeders  from  the  nose,  like  his 
brothers. 

Nephews  and  nieces — Exact  records  were  not  attainable. 
Eldest  brother  had  eight  children,  some  of  them  nose  bleeders; 
the  youngest  had  two  children,  immune.  Sisters,  both 
married,  had  as  yet  no  children. 

Altogether,  out  of  about  thirty  members  of  this  family, 


DERMATOLOGICAL  CONGRESS  167 

at  least  ten  are  or  have  been  bleeders.  None,  however,  with 
the  exception  of  the  patient  and  his  mother,  had  shown  the 
red  spots  on  the  mucosse  with  the  visible  hemorrhages. 

Treatment  had  been  with  the  fluid  extract  of  ergot  ex- 
clusively; the  patient  had  been  for  some  time  taking  thirty 
drops  three  times  a  day.  Though  given  as  a  placebo,  he 
claimed  that  the  spontaneous  hemorrhage  had  become  less 
and  less  till  now  he  had  comparatively  little  of  it. 

A  Case  of  Parapsoriasis ;  Type  Pityriasis  in  Patches 
PRESENTED  BY  DR.  WILLIAM  B.  TRIMBLE,  OF  NEW  YORK 

Woman,  aet.  twenty-six;  Polish. 

Patient  claimed  to  have  been  a  "sickly  child,"  having 
had  practically  all  the  diseases  of  childhood,  the  most  note- 
worthy being  measles  and  scarlet  fever.  She  came  to  this 
country  when  nineteen  and  soon  after  that  time  suffered  from 
suppression  of  the  menses;  this  lasted  about  six  months, 
during  which  period,  the  disease  first  made  its  appearance. 
When  shown  before  the  Congress  her  eruption  was  almost 
universal,  excepting  the  face  and  upper  part  of  the  back. 
On  the  chest,  back,  arms,  and  forearms  it  occurred  in  ill-defined, 
non-infiltrated  patches,  varying  in  size  from  a  pea  to  a  silver 
quarter.  They  were  dull  pink  at  the  periphery,  with  a  brown- 
ish tendency  toward  the  centre;  the  patches  were  apparently 
broken  up  and  coalescing  in  places;  these  mingled  with  areas 
of  healthy  skin,  giving  it  a  mottled  appearance.  The  en- 
semble was  pinkish-yellow  to  purple  in  some  places.  This 
purplish  hue  was  marked  on  the  lower  extremities,  where 
practically  no  healthy  skin  existed.  The  condition  here  greatly 
resembled  ichthyosis,  with  the  exception  of  the  color.  The 
chest  plaques  were  somewhat  like  those  of  pityriasis  rosea. 
The  lesions  were  covered  with  fine  furfuraceous  scales,  which 
left  no  bleeding  points  upon  removal.  The  scaling  was  more 
marked  on  the  lower  extremities,  the  disease  being  much  older 
in  these  regions.  One  palm  exhibited  a  tendency  to  scale 
slightly,  also  the  soles.  The  nails  were  unaffected,  and  there 
was  practically  no  itching. 

Pathology — Horny  layer  slightly  increased  in  thickness, 
nuclei  retained;  granular  layer  present,  but  in  one  or  two 


i68         SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

places  it  was  absent  or  much  thinner  and  the  parakeratosis 
over  these  points  was  more  marked.  Mild  perivascular  in- 
filtration in  upper  part  of  corium  was  composed  mainly  of 
lymphocytes. 

DR.  H.  HALLOPEAU,  of  Paris,  regarded  the  case  as  an  abnor- 
mal form  of  psoriasis. 

A  Case  of  Erythema  Induratum 

PRESENTED  BY  DR.  J.  A.  FORDYCE,  OF  NEW  YORK 
Girl,  aged  eleven,  U.  S.  Her  father  died  of  tuberculosis. 
Her  mother,  although  she  claimed  to  be  well,  looked  very 
delicate.  The  patient  had  had  measles  and  varicella.  She 
was  well  nourished  and  complained  only  of  the  skin  affection. 
The  present  eruption  began  nine  months  ago  on  her  right  leg 
as  small  deep-seated  cutaneous  nodules  which  gradually 
extended  to  the  surface  and  became  necrotic  in  the  centre. 
In  addition  to  the  closed  and  open  discrete  lesions,  she  showed 
confluent  ulcerated  areas  and  scars.  Her  left  leg  had  been 
similarly  affected  as  the  right  one  a  year  previously. 

DR.  H.  HALLOPEAU,  of  Paris,  agreed  with  Dr.  Fordyce  that  the 
case  was  one  of  erythema  indtiratum.  He  regarded  it  as  belonging 
to  the  tuberculide  group. 


THE  REGULAR  SESSION  OF  THE  CONGRESS  WAS  CALLED  TO  ORDER 

AT  ii  A.M. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  Vice-President,  in 
the  Chair. 

THE  PATHOLOGY  OF  THE  BROWN-TAIL  MOTH 

DERMATITIS 

BY  DR.  E.  E.  TYZZER,  OF  BOSTON 

The  exact  time  and  manner  of  the  introduction  of  the 
brown-tail  moth  into  this  country  is  unknown,  but  large  num- 
bers of  them  were  noted  in  1897  in  a  suburb  of  Boston.  This 
insect  feeds  upon  a  variety  of  trees,  but  the  foliage  of  certain 
fruit  trees  such  as  the  pear  and  the  plum  is  especially  pre- 
ferred. The  eggs  are  deposited  by  the  moth  early  in  July, 
and  the  young  caterpillars,  which  emerge  within  a  few  weeks, 
form  colonies  which  are  usually  situated  at  the  ends  of  twigs. 
They  grow  but  little  for  the  rest  of  the  season,  but  devote 
nearly  all  their  energy  to  the  spinning  of  nests  in  which  the 
colony  is  to  pass  the  winter.  With  the  opening  of  the  buds 
in  the  spring  the  tiny  caterpillars  emerge  and  subsequently 
grow  rapidly  with  a  corresponding  destruction  of  the  foliage. 
The  caterpillars  attain  their  growth  sometime  in  June,  spinning 
a  loose  cocoon  and  go  into  the  pupa  stage.  The  moths  emerge 
in  a  few  weeks  and  both  male  and  female  are  free-flying. 
There  is  a  tuft  of  thick  brown  fur  on  the  tails  of  the  moths, 
most  marked  on  the  females.  This  brown  fur  is  deposited 
about  the  eggs  as  they  are  laid  on  the  under  surface  of  leaves. 

The  irritating  properties  of  this  and  other  allied  species 
have  long  been  known  to  entomologists.  Perhaps  the  most 
notable  example  of  these  "stinging"  larvae  is  Cnethocampa 
pityocampa,  the  processionary  caterpillar  of  Europe. 

Attention  was  first  called  to  the  occurrence  of  the  brown- 

169 


170  SIXTH  INTERNATIONAL 

tail  moth  dermatitis  in  this  country  by  Dr.  J.  C.  White  in 
June,  190 1.  Patients  in  most  cases  gave  a  history  of  the  removal 
of  a  caterpillar  from  the  parts  affected  prior  to  the  appearance 
of  the  eruption. 

In  the  investigation  of  the  nature  of  this  peculiar  skin 
eruption  it  has  been  found  that  the  lesions  are  produced  by 
minute  barbed  hairs,  the  so-called  nettling  hairs,  which  de- 
velop on  the  caterpillars.  These  nettling  hairs  are  of  the 
form  of  straight,  tapering,  needle-pointed  shafts  possessing 
three  rows  of  recurrent  barbs.  They  vary  from  .07  to  .02 
millimetres  in  length  and  are  quite  slender.  They  possess 
a  thin  chitinous  wall  and  a  granular  interior.  These  hairs 
appear  upon  the  caterpillar  very  early  in  its  development, 
but  are  much  more  numerous  after  the  caterpillar  has  attained 
its  growth.  They  enter  into  the  structure  of  the  cocoon  and 
they  are  also  numerous  upon  the  moths,  so  that  practically 
all  stages  of  this  insect  are  poisonous.  There  is  no  evidence, 
however,  that  the  nettling  hairs  develop  upon  the  moth.  The 
nettling  hairs  are  capable  of  producing  irritation  even  after 
being  kept  for  long  periods  of  time,  and  dermatitis  has  often 
been  produced  by  handling  cocoons  and  nests  several  years 
old.  This  has  suggested  that  the  action  of  these  hairs  was 
purely  mechanical,  and  in  order  to  determine  this  point  various 
mechanical  agents  such  as  powdered  glass  wool  and  the  barbed 
hairs  of  other  caterpillars  were  rubbed  into  the  skin.  In  some 
instances  redness  and  slight  soreness  were  produced  but  nothing 
of  the  nature  of  an  urticaria. 

At  this  time  it  was  found  that  a  peculiar  reaction  takes 
place  when  nettling  hairs  are  mingled  with  a  drop  of  blood 
between  a  slide  and  cover  glass. 

The  rouleaux  of  red  blood  corpuscles  break  down,  the 
corpuscles  become  coarsely  crenated,  the  crenations  are  then 
transformed  into  slender  spines,  and  finally  the  corpuscles 
become  spherical.  The  reaction  invariably  begins  about  the 
points  of  the  nettling  hairs,  except  when  they  are  broken,  when 
it  takes  place  at  the  point  of  fracture.  This  process  does  not 
go  on  to  hemolysis.  This  reaction  with  the  red  blood  cor- 
puscles suggested  that  there  might  be  a  chemical  irritant 
carried  by  the  nettling  hairs.  The  effect  of  heat  was  tried 


DERMATOLOGICAL  CONGRESS  171 

upon  nettling  hairs  both  dry  and  suspended  in  fluids.  After 
heating  with  dry  heat  one  hour  at  i  I5°C.  they  failed  to  produce 
any  irritation  when  rubbed  into  the  skin,  and  failed  to  react 
with  the  red  blood  corpuscles.  The  structural  integrity  of  the 
nettling  hairs  is  not  destroyed  even  when  heated  to  150°  C. 

On  boiling  the  nettling  hairs  in  pyridin,  which  boils  at  106 
to  1 08°  C.,  they  retain  their  irritating  properties  and  still 
react  with  red  corpuscles.  However,  on  heating  them  in 
glycerine  at  115°  C.  their  activity  is  destroyed.  Thus  it  has 
been  found  that  the  reaction  of  the  nettling  hairs  with  the  red 
blood  corpuscles  furnishes  an  index  of  their  toxicity,  and  after 
the  above  experiments  it  seems  probable  that  the  irritation 
is  due  to  a  chemical  irritant  conveyed  by  the  nettling  hairs. 

The  next  step  was  to  determine  the  solubility  of  this  sub- 
stance. Various  reagents  were  used  both  at  room  temperature 
and  heated.  The  hairs  remain  active  after  being  treated  with 
alcohol,  chloroform,  ether,  and  pyridin.  They  become  in- 
active when  heated  in  glycerine  to  115°  C.,  but  as  this  is  the 
temperature  at  which  the  substance  was  destroyed  by  dry 
heat,  it  does  not  appear  to  be  soluble  in  glycerine.  The  nettling 
hairs  also  remain  active  after  treatment  with  dilute  acids. 

In  distilled  water  nettling  hairs  remain  active  for  long 
periods  of  time,  but  if  the  water  is  heated  to  60°  C.  the  nettling 
hairs  are  at  once  inactivated,  so  that  the  irritating  substance 
appears  to  be  soluble  in  water  at  this  temperature.  It  is  also 
found  to  be  soluble  in  dilute  alkalies  at  room  temperature.  I 
have  been  unable  thus  far  to  obtain  material  in  sufficient 
amount  to  work  with  the  irritating  substance  in  solution. 

The  pathological  processes  produced  by  the  nettling  hairs 
of  the  brown-tail  moth  have  been  studied  in  both  human 
beings  and  lower  animals.  There  are  two  types  of  dermatitis, 
the  severe  type  in  which  the  lesions  are  confluent  and  the 
inflammatory  reaction  severe,  and  the  other  milder  type  in 
which  the  small  urticarial-like  lesions  are  scattered.  The 
former  is  usually  produced  by  actual  contact  with  caterpillars, 
the  latter  is  produced  by  the  nettling  hairs  which  may  lodge 
accidentally  upon  the  surface  of  the  skin.  They  undoubtedly 
are  blown  about  and  often  lodge  upon  underclothes  as  they 
are  hung  to  dry. 


1 72  SIXTH  INTERNATIONAL 

Discussion 

DR.  JAMES  C.  WHITE,  of  Boston,  said  that  to  the  residents  of 
New  England  this  question  of  the  brown-tail  moth  was  a  very 
practical  and  important  one,  because  in  that  section  of  the  country 
these  caterpillars  had  destroyed  miles  and  miles  of  vegetation, 
they  had  ruined  many  trees,  and  had  become  a  veritable  pest. 
There  was  apparently  no  limitation  to  the  destructive  work  of 
these  insects  and  the  particular  one  described  by  Dr.  Tyzzer  was 
capable  of  producing  a  well-marked  and  wide-spread  dermatitis. 

BRIEF  NOTES  ON  VARIOUS  TOPICS 

BY  JONATHAN  HUTCHINSON,  F.R.S.,  LL.D.,  LONDON 

Among  the  subjects  which  have  especially  claimed  my 
attention  during  the  last  few  years  I  may  venture  to  mention 
the  following: 

Lichen  Scrofulosorum  and  Darter's  Dermatosis 

Cases  have  from  time  to  time  come  under  notice  which 
seem  to  imply  that  we  ought  to  much  widen  our  conception 
of  what  we  mean  by  "lichen  scrofulosorum. "  Hebra's 
original  description  and  plates  included  cases  of  much  greater 
severity  and  less  easy  curability  than  those  to  which  in  English 
practice  that  diagnosis  is  at  present  carefully  restricted.  It 
is  not  wise,  nor  is  it  consistent  with  clinical  truth,  to  construct 
definitions  which  exclude  all  complicated  cases  or  those  of 
aberrant  severity.  The  scrofulous  affections  of  the  pilo- 
sebaceous  system  of  the  skin  are  by  no  means  always  pure 
"  lichens  "  nor  do  they  always  tend  to  disappear  unless  very 
efficient  treatment  is  adopted.  The  Vienna  school  has  long 
recognized  this,  and  complications  with  acne,  eczema,  and 
sycosis  are  I  think  quite  correctly  recognized  among  those 
of  "  lichen  scrofulosorum."  On  this  point  Kaposi's  Hand- 
Atlas  gives  useful  information.  The  malady  which  I  would 
especially  desire  now  to  add  to  this  category  is  that  which  has 
become  known  as  Darier's  dermatosis.  The  careful  examina- 
tion of  two  well-marked  examples  of  this  malady,  in  both  of 
which  the  so-called  coccidia  were  abundantly  present,  con- 
vinced me  that  they  were  only  aggravated  and  long  neglected 


DERMATOLOGICAL  CONGRESS  173 

cases  of  lichen  scrofulosorum.  These  cases  are  illustrated 
and  the  question  discussed  (by  myself)  in  a  recent  fasciculus 
of  the  New  Sydenham  Society's  Clinical  Atlas. 

On  Insect  Attacks  as  Causing  Eruptions 

The  effects  resulting  either  immediately  or  remotely 
from  the  attacks  of  insects  have  I  think  been  less  care- 
fully recognized  than  they  deserve.  Almost  all  the  acute 
and  very  irritable  eruptions  commonly  known  by  the  name 
of  "lichen  urticatus"  or  some  similar  one  are,  I  feel  con- 
fident, almost  always  due  to  flea  bites,  while  those  which 
result  in  the  chronic  condition  known  as  "urticaria 
pigmentosa"  are  in  parallel  relationship  with  those  of  the 
bedbug.  It  is  certainly  a  mistake  to  imagine  that  the  local 
effects  of  insect  punctures  are  always  transitory.  These 
effects  vary  within  very  wide  limits  indeed,  in  connection  with 
the  proclivities  of  the  patient.  Another  point  of  great  im- 
portance is  that  these  attacking  insects  manifest  very  marked 
aptitudes  of  selective  preference.  Fleas  will  attack  one 
child  in  a  family  and  avoid  all  the  rest  and  it  is  the  same 
with  bugs,  gnats,  and  flies.  The  character  and  duration  of  the 
irritation  evolved  will  vary  with  the  species  of  insect  and,  it 
may  possibly  be,  also  with  the  purposes  for  which  its  pro- 
boscis has  just  previously  been  used.  Still  more  will  they 
vary  with  the  susceptibilities  and  proclivities  of  the  victim. 
A  flea  may  cause  in  one  person  only  a  minute  spot  of  erythema, 
in  another  a  large  urticarious  wheal,  and  in  a  third  a  vesicle 
or  even  a  bulla  which  might  be  regarded  as  "pemphigus." 

Inasmuch  as  we  seldom  or  never  get  any  help  from  direct 
questions  put  to  the  mother  or  nurse  it  is  well  to  remember 
certain  rules  which  will  usually  guide  us  right  in  diagnosis. 

ist.  Is  the  eruption  one  which,  like  urticaria  pigmentosa, 
occurs  almost  solely  amongst  the  poor  ? 

2d.  Does  the  eruption  come  out  in  crops  and  are  the 
first  crops  usually  local  only? 

3d.  Are  the  first  crops  often  or  usually  observed  after 
sleep  ? 

4th.  Have  the  attacks  been  observed  after  change  of 
home  ? 


174  SIXTH  INTERNATIONAL 

5th.     Is  the  patient  a  child  or  young  person  ? 

6th.     Is  any  family  proclivity  known  ? 

7th.  Does  the  liability  to  fresh  eruptions  cease  if  the 
patient  be  taken  into  a  clean  hospital,  or  on  change  of  place  of 
residence  ? 

As  a  rule,  the  liability  to  suffer  severely  from  insects 
diminishes  as  age  advances  and  often  comes  practically  to  an 
end.  The  consequences  of  insect  irritation  may,  however,  last 
long  after  we  have  gotten  rid  of  the  original  cause.  A  pruri- 
ginous  state  of  skin  may  become  established  by  frequent 
recurrences  and  may  last  a  lifetime. 

Careful  investigation  in  the  direction  which  is  now  sug- 
gested would,  I  feel  confident,  result  in  placing  in  one  category 
at  least  a  dozen  eruptions  which  have  in  our  systematic  works 
received  different  names.  It  would  greatly  simplify  matters 
and  save  the  waste  of  much  useless  ingenuity  in  diagnostic 
description.  (See  New  Sydenham  Society's  Atlas  for  1903,  4 
and  5.) 

Chancres  from  Flea  Bites 

I  have  seen  two  very  definite  cases  in  which  primary 
syphilitic  sores  were  caused  on  the  leg  by  fleas  obtained  in 
omnibuses,  and  several  others  in  which  this  mode  of  infection 
was  suspected.  In  the  tropics  the  form  of  syphilis  vulgarly 
called  "yaws"  is  probably  almost  always  transferred  by 
either  fleas  or  flies. 

Yaws  a  Form  of  Syphilis 

I  believe  it  is  now  generally  accepted  that  the  diseases 
which  have  been  named  yaws,  parangi,  tropical  framboesia, 
sibbeus,  morula,  etc.,  are  nothing  but  variants  of  syphilis. 
Usually  they  result  from  non-venereal  or  erratic  chancres, 
but  often  the  primary  sore  is  on  the  genitals.  They  are 
curable  by  the  remedies  for  syphilis  and  the  alleged  exceptions 
to  the  rule  that  the  one  prevents  the  other  are  exceedingly 
few.  It  cannot  even  be  admitted  that  they  constitute  well 
characterized  varieties  of  syphilis,  for  it  is  clear  that  in  the 
best  characterized  forms  of  each  they  are  transmittable ;  that 
typical  yaws  may  occur  from  contagion  from  typical  syphilis 


DERMATOLOGICAL  CONGRESS  175 

and  vice  versa.  Tropical  frambcesia  is  by  no  means  ex- 
clusively tropical,  and  where  it  is  most  prevalent  a  large 
majority  of  its  associated  forms  do  not  depart  from  the  more 
ordinary  ones  of  syphilis.  There  are  all  gradations  between 
the  two.  It  is  clear  that  their  supposed  distinctions  result 
from  race,  climate,  and  idiosyncrasy  separately  or  in  com- 
bination. 

Lymphangioma  or  Lupus  Lymphaticus  ? 

Many  years  ago  when  I  first  described  the  skin  affection 
which  has  since  been  known  as  lymphangioma  I  ventured  to 
name  it  "  lupus  lymphaticus.  "  The  name  was  intended  to 
imply  the  belief  that  it  was  in  the  same  sort  of  relationship 
to  the  tubercle  bacillus  that  the  other  forms  of  lupus  are ;  its 
peculiarities  depending  upon  those  of  the  tissue  attacked. 
It  is  locally  infective,  remains  local,  but  spreads  serpiginously 
and  produces  satellites  and  leaves  scars.  It  occurs  chiefly 
in  the  young  and  in  those  often  of  tuberculous  families.  I 
have  recently  seen  two  examples  of  it  in  association  with 
lupus  vulgaris  and  one  in  which  two  or  three  years  previously 
glands  had  been  excised  from  the  child's  neck,  in  which  the 
bacillus  had  been  recognized  beyond  doubt.  I  am  inclined 
to  adhere  to  my  original  name  as  being  the  most  appropriate 
of  those  which  have  been  proposed.  I  should  like,  however, 
to  modify  it  so  as  to  include  vascular  structures,  since  it  un- 
doubtedly often  attacks  nasvoid  tissues  and  is  always  at- 
tended by  venous  as  well  as  lymph  dilatations.  The  generic 
term  lupus  should  be  resolutely  retained,  since  it  is  the  key 
to  the  more  important  characteristics  of  the  disease. 

Melanotic  Lentigo  of  the  Lips  and  Mouth 

The  topic  the  most  nearly  approaching  to  novelty  which 
has  recently  claimed  my  interest  is  that  to  which  the  above 
name  refers.  It  consists  in  the  formation  on  the  lips  and 
adjacent  skin  and  inside  the  mouth  on  the  gums  and  palate 
of  discrete  spots  or  patches  of  deep  brown  or  jet-black  tint. 
They  are  sometimes  associated  with  conspicuous  brown  freck- 
les in  the  face,  whilst  inside  the  mouth  they  much  resemble 


1 76  SIXTH  INTERNATIONAL 

the  markings  on  a  dog's  lips  and  gums.  I  have  now  seen  seven 
or  eight  good  examples  of  this  affection.  It  is  not  often 
noticed  at  birth  but  usually  in  early  childhood.  It  may,  how- 
ever, develop  de  novo  in  adult  life.  Once  I  have  seen  it  in 
twins  and  once  in  a  brother  and  sister  of  nearly  the  same  age. 
I  have  not  seen  it  in  association  with  xeroderma  pigmentosum 
(better  lentigo  juvenilis  maligna)  and  only  in  one  instance 
have  malignant  processes  (melanotic)  followed.  It  is  I  think 
clearly  in  close  relationship  with  the  xeroderma  pigmentosum 
and  like  it  prone  to  become  a  matter  of  family  inheritance. 
A  portrait  of  the  cases,  which  occurred  in  twin  sisters,  was 
published  ten  years  ago.  One  of  the  twins  has  since  died. 
In  the  survivor  the  conditions  now  present  are  almost  exactly 
as  they  were.  At  the  recent  meeting  of  the  British  Medical 
Association  at  Exeter  I  exhibited  portraits  from  three  other 
cases. 


IDIOPATHIC    MULTIPLE     HEMORRHAGIC    SAR- 
COMA (KAPOSI) 

BY  DR.  M.  B.  HARTZELL,  OF  PHILADELPHIA 

In  1872  Kaposi i  first  called  attention  to  an  unusual  and 
remarkable  affection  of  the  skin  characterized  by  the  occur- 
rence of  deeply  pigmented  infiltrated  patches  and  small 
tumors,  situated  almost  invariably  on  the  extremities,  fol- 
lowed after  several  years  by  visceral  metastases  and  death, 
for  which  he  proposed  the  name  "idiopathic  multiple  pig- 
mented sarcoma,"  a  name  which  he,  twenty  years  later, 
changed  to  idiopathic  multiple  hemorrhagic  sarcoma,  as 
being  more  accurately  descriptive  of  the  disease.  At  the 
time  of  this  first  communication  he  had  seen  but  five  cases, 
but  this  number  had  increased  to  twenty-five  up  to  the  time 
of  the  publication  of  the  last  edition  of  his  well-known  treatise 
on  diseases  of  the  skin.  He  regarded  the  malady  as  a  typical, 
although  special  and  peculiar,  form  of  round-celled  sarcoma, 
with  the  occasional  occurrence  of  characteristic  spindle  cells. 

1  Archiv  f.  Dermatologie  u.  Syphilis,  Bd.  iv.,  1872. 


DERMATOLOGICAL  CONGRESS  177 

Soon  after  the  appearance  of  Kaposi's  paper  other  observers 
began  to  report  similar  cases,  and  the  list  has  steadily  though 
slowly  grown,  until  the  number  of  recorded  cases  is  now 
something  over  one  hundred.  Although  the  affection  is  a 
relatively  rare  one,  most  of  those  who  have  written  about  it 
having  seen  but  a  small  number  of  cases,  yet  one  observer, 
De  Amicis,1  reports  having  seen  more  than  fifty,  by  far  the 
largest  number  observed  by  any  single  individual.  While  the 
affection  seems  to  be  peculiar  to  no  country  or  race,  the  great 
majority  of  the  cases  on  record  have  been  reported  by  Euro- 
pean observers,  and  fully  one-half  of  these  from  the  northern 
provinces  of  Italy.  The  number  of  cases  reported  in  America 
is  extremely  small,  and  some  of  these  occurred  in  foreign-born. 
For  this  reason,  among  others,  I  have  thought  it  might  be  worth 
while  to  add  a  new  and  typical  case  of  this  very  remarkable 
disease  to  the  list  of  cases  occurring  in  native-born  Americans. 
S.  M.,  sixty-nine  years  old,  a  travelling  salesman  by  occupa- 
tion, in  excellent  general  health,  came  under  my  observation  in 
January  of  this  year,  seeking  advice  for  an  affection  of  the 
legs  which  presented  the  following  features:  On  the  dorsum 
of  the  left  foot  and  the  anterior  surface  of  the  leg  were  numerous 
round,  oval,  and  irregularly-shaped,  slightly  elevated,  or  on 
a  level  with  the  healthy  skin,  very  dark-brown  and  slate- 
colored,  for  the  most  part  smooth,  but  in  places  slightly  scaly, 
firm  patches.  On  the  calf  the  disease  consisted  of  many 
pea-  to  hazel-nut-sized,  confluent  firm  nodules  similar  in  color 
to  the  patches  on  the  anterior  surface  of  the  leg,  forming  a 
large  uneven  patch  covering  the  entire  calf.  Here  and  there 
were  a  few  coin-sized,  depressed,  scaly,  less-deeply  pigmented 
areas  which,  according  to  the  statement  of  the  patient, 
represented  patches  of  nodules  which  had  undergone  partial 
involution.  Over  the  outer  malleolus  was  a  single  nut- 
sized,  pedunculated  tumor,  projecting  considerably  above 
the  surface,  which  gave  the  patient  much  annoyance  because 
of  the  pressure  exerted  on  it  by  the  shoe,  and  the  frequent 
injury  which  it  suffered,  owing  to  its  exposed  situation,  by 
being  caught  by  the  clothing  and  the  bedclothing,  considerable 

1  Monatshefte  f.  prakt.  Dermatologie,  Bd.  xxv.,  1897. 

VOL.  I. — 12 


178  SIXTH  INTERNATIONAL 

hemorrhage  taking  place  from  it  at  times.  Upon  the  right 
leg  the  disease  was  much  less  extensive,  the  lesions  being  com- 
paratively small  in  number,  smooth,  flat,  without  any  ten- 
dency to  the  formation  of  tumors.  The  left  leg  was  several 
inches  larger  in  circumference  than  the  right  one,  was  very 
firm  to  the  touch,  but  did  not  pit  on  pressure.  There  were 
marked  itching  and  some  burning,  but  never  positive  pain, 
although  walking  was  somewhat  interfered  with  by  the  swell- 
ing of  the  left  leg  and  stiffness  of  the  skin  about  the  ankles. 
The  disease  had  begun  fourteen  years  previously,  with  in- 
tense itching  at  the  root  of  the  toes  and  smooth  pigmentation 
of  the  dorsum  of  the  foot,  and  had  remained  limited  to  the  left 
extremity  until  two  years  ago,  when  it  began  to  appear  on  the 
right  foot  and  leg.  The  numerous  tumors  on  the  left  calf 
were  first  noticed  some  five  or  six  years  ago.  With  the  ex- 
ception of  a  single  thumbnail-sized  patch  on  the  inner  sur- 
face of  the  left  thigh,  the  disease  was  strictly  limited  to  the 
legs  and  feet. 

The  treatment  employed  consisted  in  the  local  use  of  anti- 
pruritic  lotions  for  the  relief  of  the  severe  itching  which  gave 
the  patient  much  trouble  at  times,  the  internal  administration 
of  arsenic  in  fairly  large  doses  by  the  mouth,  and  the  use  of 
the  X-ray.  Up  to  the  present  time  some  fifty  X-ray  exposures 
have  been  made,  chiefly  to  the  left  leg,  at  intervals  of  three 
to  five  days,  each  exposure  lasting  from  seven  to  ten  minutes. 
Owing  to  a  severe  and  prolonged  attack  of  thoracic  zoster, 
which  was  probably  arsenical  in  origin,  the  treatment  was 
suspended  for  four  weeks,  and  has  been  carried  out  somewhat 
irregularly  since.  The  large  nodular  patch  on  the  left  calf 
was  the  first  to  be  subjected  to  X-ray  treatment,  and  showed 
decided  improvement  after  twenty-five  exposures,  the  small 
tumors  becoming  less  prominent  and  losing  pigment;  and  a 
similar  improvement  has  been  observed  in  all  the  parts  sub- 
jected to  this  treatment.  The  itching  which  was  the  chief 
subjective  symptom,  almost  entirely  disappeared  so  that 
the  patient  no  longer  found  it  necessary  to  use  the  lotion 
which  had  been  given  him  for  the  relief  of  this  most  annoying 
symptom.  At  an  examination  made  within  a  day  or  two, 
striking  improvement  was  found;  not  only  was  there  a  de- 


DERMATOLOGICAL  CONGRESS  179 

cided  diminution  in  the  size  of  the  tumors  and  a  noticeable 
decrease  in  the  amount  of  the  pigment,  but  the  swelling  of 
the  left  leg  had  diminished  to  such  a  degree  that  it  was  but 
very  little  larger  than  the  right  one.  It  is  perhaps  worthy 
of  note  that,  notwithstanding  the  number  of  X-ray  exposures, 
there  has  never  been  the  slightest  evidence  of  dermatitis. 
May  this  immunity  be  due  to  a  protective  action  exerted  by 
the  deep  pigmentation  of  the  skin? 

Because  of  its  exposed  position  and  consequent  frequent 
injury,  the  tumor  over  the  left  external  malleolus  was  excised 
and  subjected  to  microscopic  examination.  This  examination 
showed  that,  apart  from  a  moderate  increase  in  the  thickness 
of  the  corneous  layer,  the  epidermis  was  normal.  The  papil- 
lary layer  of  the  corium  had  entirely  disappeared  and  the 
corium  itself  was  almost  entirely  replaced  by  a  cavernous  tissue, 
which  under  a  moderate  magnification  resembled  an  angioma. 
It  was  composed  of  numerous  large  round  and  oval  cavities, 
with  thin  walls  filled  with  blood,  with  here  and  there  small 
islets  of  round  or  spindle  cells  between,  and  in  which  was 
an  abundance  of  golden-brown  pigment  granules.  Under  a 
sufficiently  high  power  it  could  be  seen  that  the  blood-filled 
spaces  were  lined  by  endothelial  cells,  and  that  the  round 
and  spindle  cells  were  contained  in  a  rather  coarse  fibrous 
mesh-work.  In  most  instances  the  spindle-cell  tracts  sur- 
rounded capillaries,  the  long  axis  of  the  cells  running  parallel 
with  the  walls  of  the  vessels.  The  pigment,  which  was  present 
in  great  abundance,  was  situated  both  within  the  cells  and 
between  them,  in  the  former  case  frequently  obscuring  more 
or  less  completely  the  outlines  of  the  cells.  The  cell  elements 
of  the  tumor  were  in  all  probability  entirely  of  the  spindle-cell 
variety,  the  apparently  round  cells  being  most  likely  trans- 
verse sections  of  spindle-shaped  cells.  In  addition  to  the 
blood  in  the  cavities  already  described,  there  were  numerous 
interstitial  hemorrhages  visible  in  various  parts  of  the 
tumor.  (Plate  v.) 

We  are  practically  without  any  definite  knowledge  of  the 
causes,  predisposing  or  direct,  of  this  very  remarkable  malady. 
Age  seems  to  have  little  or  no  influence  upon  its  occurrence, 
cases  having  been  observed  at  all  ages  between  five  and  eighty, 


i8o  SIXTH  INTERNATIONAL 

although  the  great  majority  occurred  in  adult  life.  Semenow, l 
who  saw  ten  cases  in  Stoukowenkoff's  clinic  within  the  com- 
paratively short  period  of  five  years,  noted  that  a  large  pro- 
portion of  these  had  been  exposed  to  more  or  less  severe  and 
prolonged  cold,  and  was  inclined  to  attribute  a  causative 
influence  to  this  factor.  In  one  of  his  cases  the  bluish  nodules 
occasionally  disappeared  spontaneously,  but  always  reap- 
peared in  damp  and  cold  weather.  Micro-organisms  have 
been  diligently  searched  for,  but  without  success.  It  is  true 
that  Pringle 2  has  reported  the  finding  of  bacilli  in  two  cases, 
but  other  investigators  have  failed  to  confirm  this  finding. 
Bernhardt3  believes  the  parasitic  theory  would  best  explain 
its  origin,  but  his  bacteriological  investigations,  like  those 
of  others,  have  been  fruitless.  This  author  reports  a  case  in 
which  frequent  attacks  of  erysipelas  occurred,  but  instead 
of  exerting  a  favorable  influence  upon  the  course  of  the  malady, 
as  in  some  other  forms  of  sarcoma,  these  were  always  followed 
by  the  appearance  of  fresh  sarcoma  nodules  in  the  areas  affected 
by  the  erysipelas. 

The  course  of  the  disease  is  usually  quite  slow,  extending 
over  years,  new  lesions  appearing  at  longer  or  shorter  intervals 
and  slowly  enlarging.  Exceptionally,  however,  lesions  may 
appear  very  suddenly.  Semenow  has  seen  a  large  blue  patch 
appear  in  the  course  of  a  single  night.  This  sudden  appearance 
of  extensive  new  lesions  is  due,  according  to  Bernhardt,  to 
the  occurrence  of  abundant,  sharply  circumscribed  hemor- 
rhages into  the  skin  which  simulate  sarcomatous  nodules. 
The  mucous  membranes  may  be  implicated  comparatively 
early  in  the  course  of  the  affection,  as  evidenced  by  the  ap- 
pearance of  pigmented  patches  on  the  buccal  and  palatal 
surfaces.  Visceral  metastases  occur  late  and  usually  soon 
bring  about  a  fatal  termination.  It  is  of  interest  and  im- 
portance to  note  that  the  bones  of  the  extremities  may  be 
involved  in  the  morbid  process.  In  one  of  Bernhardt 's 
cases  disease  of  the  bones  of  the  foot  was  demonstrated  by  the 

1  Monatshefte  f.  prak.  Dermatologie,  Bd.  xxv.,  1897. 

2  Comptes  Rendus  Congres  International  de  Dermatologie  et  de  Syphili- 
graphie,  Paris,  1890. 

3  Archiv  f.  Dermatologie  u.  Syphilis,  Bd.  Ixii.,  1902. 


DERMATOLOGICAL  CONGRESS  181 

X-ray,  and  after  amputation  it  was  found  that  the  phalanges, 
with  some  of  the  metatarsal  and  tarsal  bones,  were  almost 
destroyed,  being  converted  into  a  spongy  mass.  Halle  likewise 
reports  a  case  in  which  the  bones  of  the  great  toe,  enucleated 
on  account  of  severe  pain,  were  found  to  be  completely  de- 
stroyed and  converted  into  sarcomatous  tissue.  Although  a 
fatal  termination  is  to  be  expected  when  internal  metastases 
take  place,  the  patient's  health  is  usually  astonishingly  well 
preserved  until  this  time,  the  disease  apparently  exerting 
little  or  no  influence  upon  the  general  economy  so  long  as 
internal  organs  are  not  invaded.  Spontaneous  involution  of 
some  of  the  lesions,  more  or  less  complete,  not  infrequently 
takes  place,  as  in  the  case  I  have  reported  in  this  paper.  The 
small  tumors  become  less  prominent,  grow  paler,  become 
scaly,  and  finally  sink  below  the  level  of  the  surrounding  skin. 
On  the  other  hand,  recurrences  may  follow  extirpation  of 
nodules. 

Owing  to  the  striking  and  peculiar  symptoms  of  the  disease, 
all  observers  are  of  one  mind  as  to  its  clinical  characteristics, 
but  there  is  considerable  divergence  of  opinion  as  to  its  histo- 
pathology,  and  more  especially  as  to  its  place  in  nosology. 
While  most  authors  agree  with  the  view  of  Kaposi  that  the 
affection  is  a  form  of  sarcoma,  a  not  inconsiderable  minority 
regard  its  sarcomatous  nature  as  more  or  less  doubtful,  while 
a  few  deny  it  absolutely.  Most  of  those  who  have  studied 
its  histopathology  found  the  lesions  composed  of  spindle- 
celled  elements,  either  entirely  or  in  large  part;  a  few  found 
only  round  or  oval  cells,  while  Kaposi  and  Perrin1  found  both 
types  of  cell.  Bernhardt  maintains  that  this  form  of  sarcoma 
is  exclusively  spindle-celled. 

De  Amicis,  whose  experience  with  this  malady  has  prob- 
ably been  larger  than  that  of  any  other  author,  believes  it  a 
well-defined  type  of  disease  whose  nosographic  position  lies 
between  granuloma  and  real  sarcoma  and  whose  nature  is 
unknown.  On  account  of  the  severe  pains  which  frequently 
accompany  its  early  stages,  the  oedema,  the  severe  itching, 
the  increased  activity  of  the  secretory  organs,  the  symmetrical 

>  Th£se  de  Paris,  1886. 


1 82  SIXTH  INTERNATIONAL 

distribution  of  the  lesions,  the  collection  of  pigment  which  he 
found  in  the  cells  of  the  spinal  ganglia,  and  finally  because 
of  some  changes  in  the  nerves  themselves,  Semenow  believes 
that  the  affection  is  closely  related  to  the  nervous  system  in 
its  origin.  Bernhardt's  investigations  lead  him  to  the  con- 
clusion that  it  is  a  sarcoma  originating  in  the  perithelium 
of  the  blood  vessels — a  perithelioma — of  unknown  cause. 
Halle  looks  upon  it  as  a  disease  of  the  vessel  system  and  rejects 
the  theory  of  its  microbic  origin;  he  believes  it  rather  due  to 
complicated  processes  taking  place  in  the  organism  itself, 
Sellei1  considers  that  recent  histological  investigations  have 
shown  that  the  affection  is  not  a  sarcoma — is  not  even  to 
be  reckoned  among  the  new  growths — but  is  a  granuloma, 
and  proposes  to  call  it  "granuloma  multiplex  hczmorrhagicum." 
The  study  of  my  own  case,  and  of  the  literature  of  the  subject, 
leads  me  to  agree  with  the  views  of  those  who  regard  the 
malady  as  a  sarcoma  of  special  type,  and  especially  with 
the  views  of  those  who  consider  it  a  disease  of  the  blood 
vessels;  certainly  these  play  an  important  part  in  its 
production. 

In  view  of  the  favorable  reports  of  Kobner,2  Sherwell,3  and 
more  recently  of  De  Amicis,  the  use  of  arsenic  is  certainly 
to  be  advised  in  the  treatment  of  this  grave  disorder.  At  the 
Congress  at  Rome,  De  Amicis  reported  eleven  cases  treated 
by  subcutaneous  injections  of  arsenic;  in  five  of  these  there 
was  no  noteworthy  benefit;  in  two  there  was  essential  im- 
provement, and  in  four  the  course  of  the  disease  was  arrested. 
Later  he  reported  two  additional  cases ;  one,  a  boy  fifteen  years 
old,  in  whom  a  cure  was  obtained  after  one  hundred  injections ; 
the  other,  a  man  fifty-two  years  of  age,  in  whom  almost  complete 
recovery  took  place.  On  the  other  hand,  Kaposi,  Bernhardt, 
and  others  report  nothing  but  complete  failure  in  their  trials 
with  this  drug.  The  chief  difficulty  in  determining  the  value 
of  any  method  of  treatment  in  this  affection  lies  in  the  fact 
that  spontaneous  involution  of  the  lesions  may  take  place, 
and,  in  rare  cases,  even  complete  recovery,  as  in  the  remark- 

1  Monatshefte  /.  prak.  Dermatologie,  Bd.  xxxi. 

2  Berliner  klin.  Wochenschrift,  1883. 

3  Jour.  Cutaneous  and  Genito-  Urinary  Diseases,  1897. 


PLATE  V— To  Illustrate  Dr.  M.  B.  Hartzell's  Article. 


Idiopathic  Multiple  Haemorrhagic  Sarcoma 
16  mm.  Obj.     Compens.     Oc.  4. 
a. — Spindle  cell  areas, 
b. — Cavities  containing  blood. 


DERMATOLOGICAL  CONGRESS  183 

able  case  reported  some  years  ago  by  Hardaway.1  Quite 
recently  the  X-ray  has  been  employed  with  some  benefit. 
Halle  reports  that,  after  producing  a  reaction  of  the  first 
degree  with  this  agent,  there  was  a  decrease  in  the  infiltration 
and  pigmentation;  and  Selhorst  and  Polano  observed  some 
improvement  after  the  use  of  the  ray.  In  my  own  case 
there  was  an  undoubted  diminution  in  the  infiltration  of  the 
skin  and  a  decided  lessening  of  the  swelling  of  the  limb,  with 
decrease  of  pigment  after  prolonged  X-ray  treatment. 

Discussion 

DR.  EDWARD  H.  SHIELDS,  of  Cincinnati,  referred  to  several 
cases  of  this  character  which  he  saw  in  the  clinic  of  Prof.  Kaposi. 
One  case  was  of  particular  interest — a  woman  with  multiple 
lesions  suddenly  developed  a  temperature;  with  the  appearance 
of  the  fever  the  lesions  disappeared,  leaving  no  ocular  trace  of 
the  disease.  A  section  showed  complete  absorption  of  the  cellular 
elements. 

DR.  ROLLIN  H.  STEVENS,  of  Detroit,  said  that  for  the  past  two 
years  he  has  had  under  observation  at  Ann  Arbor,  a  case  of  this 
disease  very  similar  to  the  one  reported  by  Dr.  Hartzell.  The 
patient  was  a  man,  seventy-two  years  old,  a  native  of  Michigan, 
in  whom  the  disease  had  developed  about  five  years  before,  after 
a  two  years'  residence  in  Denver  and  the  West.  He  first  noticed 
a  swelling  of  the  feet  and  later  a  number  of  dark,  bluish  nodules 
on  the  backs  of  the  feet  and  hands,  with  the  subsequent  develop- 
ment of  lesions  on  the  palms  and  soles.  These  extended  to  the 
arms  and  legs,  and  later  lesions  developed  on  the  palate,  tongue, 
penis,  back,  neck,  and  eyelids.  He  had  a  tumor  on  each  eyelid, 
one  about  the  size  of  a  cherry  and  the  other  as  large  as  a  plum. 
These  were  excised  and  sent  to  the  pathological  department  of 
the  University  of  Michigan,  where  sections  were  examined  and 
pronounced  to  be  fibroma  molluscum,  the  young  connective 
tissue  cells  resembling  the  spindle  cells  of  sarcoma.  Subsequent 
examinations  of  sections  taken  from  one  of  the  lesions  on  the  foot 
showed  the  true  spindle  cells  of  sarcoma.  The  tumors  in  the 
soles  of  the  feet  became  papillomatous  and  sensitive. 

DR.  SAMUEL  SHERWELL,  of  Brooklyn,  said  that  about  1892 
he  wrote  an  article'  on  multiple  sarcoma  and  gave  report  of  a  case 

1  Jour.  Cutaneous  and  Genito-Urinary  Diseases,  1890. 


i84  SIXTH  INTERNATIONAL 

which  was  published  in  the   American   Journal  of   the   Medical 
Sciences,  Oct.,  1892. 

In  this  paper  he  had  claimed  good  results  from  the  use  of 
arsenic  in  large  dosage.  He  referred  to  it,  as  it  might  prove  of 
use  to  those  interested  in  the  subject,  showing  as  it  did  what 
might  be  accomplished  by  medical  means  alone,  as  an  inhibitive 
or  prophylactic,  and  even  curative  method. 

DR.  HARTZELL,  in  closing  the  discussion,  said  the  exact  place 
in  nosology  of  this  disease  was  still  uncertain.  Some  regarded 
the  malady  as  sarcoma;  others  as  granuloma. 


MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA 
BY  DR.  M.  L.  HEIDINGSFELD,  OF  CINCINNATI 

The  subject  of  multiple  benign  dermatological  new  growths 
is  enveloped  with  considerably  more  haze  than  the  long  line 
of  careful  clinical  observations  and  pathological  investigations 
seemingly  warrant.  This  haze,  which  was  notably  absent 
from  Kaposi's  earliest  classical  description  of  lymphangioma 
tuberosum  multiplex  in  1892,  has  materially  increased  with 
the  successive  investigations  of  Jacquet  and  Darier  on  hydra- 
dlnomes  e"ruptifs;  Torok,  on  syringo-cystadenom ;  Brooke, 
on  epithelioma  adenoides  cysticum;  Fordyce,  on  multiple 
benign  cystic  epithelioma ;  Balzer  and  Menetrier,  on  adenoma 
s6bac6s;  Pringle,  on  adenoma  sebaceum,  etc.  This  haze,  at 
least  in  a  measure,  has  been  doubtless  due  to  over-attention 
to  minor  clinical  and  pathological  details,  and  has  resulted  in 
overwhelming  this  class  of  dermatological  affections  with  a 
mass  of  complexing  synonyms. 

From  the  earliest  there  has  been  a  constant  conflict  of 
opinion  among  those  in  authority  as  to  whether  the  cases  thus 
far  reported  can  be  consistently  divided  into  a  number  of 
distinct  groups  or  collected  with  greater  propriety  and  con- 
venience into  a  single  class.  The  three  principal  groups  into 
which  most  of  the  cases  have  been  readily  placed  are:  (i)  mul- 
tiple benign  cystic  epithelioma,  (2)  lymphangioma  tubero- 
sum multiplex,  (3)  adenoma  sebaceum,  to  which  a  possible 
fourth  can  be  added,  (4)  linear  naevi.  The  clinical  char- 


DERMATOLOGICAL  CONGRESS  185 

acteristics  of  these  various  groups  have  been  sufficiently  long 
and  well  established  to  permit  their  ready  recognition,  and  in 
themselves  require  but  little  comment.  In  multiple  benign 
cystic  epithelioma  the  lesions  are  usually  small,  pin-head  to 
split-pea  in  size,  glistening,  translucent  in  appearance,  yellow- 
ish, pinkish,  or  bluish  white  in  color,  rarely  ulcerated,  but 
sometimes  centrally  depressed,  situated  for  the  most  part 
on  the  face,  principally  at  the  root  of  the  nose,  cheeks,  forehead, 
ears,  and  chin,  bilaterally  symmetrical,  but  grouped.  The  cases 
are  mostly  hereditary,  females,  develop  at  puberty,  and  con- 
sist pathologically  of  masses — of  epidermal  origin — of  irregular 
interlacing  epithelial  strands,  broad  angular  in  outline,  giving 
off  smaller  strands,  and  interspersed  with  oval  or  roundish 
cysts  containing  colloid  or  cornified  epithelium.  The  nodules 
develop  slowly,  and  after  attaining  a  moderate  development 
usually  remain  stationary  in  size.  The  lesions  in  adenoma 
sebaceum  are  very  similar  to  those  in  multiple  benign  cystic 
epithelioma,  but  are  usually  more  symmetrical  in  distribution, 
and  reddish  brown  in  color.  The  pathological  change  is  usually 
a  hyperplasia  of  the  sebaceous  glands,  which  is  by  no  means 
constant,  as  will  be  referred  to  later.  Lymphangioma  tu- 
berosum  multiplex  is  characterized  by  small  roundish  or  oval 
lesions,  pin-head  to  a  split-pea  or  larger  in  size,  firmly  im- 
bedded in  the  cutis  and  slightly  elevated  above  the  surface, 
irregularly  but  bilaterally  distributed  over  the  anterior  aspect 
of  the  thorax  and  the  fossa  of  the  neck.  Pathologically  they 
are  mostly  endothelial  in  character,  derived  from  lymph  and 
blood  vessels.  Linear  naevi,  when  linear  in  distribution  and 
unilateral  in  character,  are  readily  recognizable  and  require 
no  special  clinical  comment,  but  when  they  occur  in  the  form 
of  multiple,  bilaterally  distributed,  discrete  lesions,  with  a 
distribution  analogous  to  the  affections  already  enumerated, 
they  can  present  clinical  and  pathological  features  difficult 
of  differentiation. 

All  these  groups  present  many  common  clinical  and  pa- 
thological characteristics.  Most  authorities  concede  to  them 
an  embryonic  congenital  origin  from  misplaced  epithelial 
tissue.  Most  of  them  are  stimulated  by  puberty  to  their 
greatest  degree  of  new  growth  and  development.  The  patho- 


i86  SIXTH  INTERNATIONAL 

logical  findings  in  each  group  are  exceedingly  varied,  but,  group 
compared  with  group,  possess  much  in  common.  They  often 
present  common  clinical  characteristics  in  size,  color,  sta- 
bility, distribution  of  the  lesions,  and  their  hereditary  and 
painless  character.  Their  common  though  infrequent  change 
to  malignancy  has  also  been  noted.  Most  authors,  while  still 
maintaining  separate  groups  for  certain  clinical  considerations, 
are  frank  to  admit  that  they  possess  much  in  common  to 
permit  a  unification  and  simplification  of  this  particular 
class  of  dermatological  cases.  Crocker1  (p.  984),  who  is  a 
strong  advocate  for  the  division  of  these  cases  into  separate 
groups,  is  frank  to  admit  that  multiple  benign  cystic  epi- 
thelioma,  lymphangioma  tuberosum  multiplex,  and  adenoma 
sebaceum  possess  many  common  characteristic  traits;  that 
certain  clinical  features  which  serve  to  distinguish  them  from 
each  other  possess  merely  relative  value;  that  the  microscope 
must  often  decide,  and  the  pathology  still  awaits  more  common 
and  general  agreement. 

Wilhelm,  in  presenting  a  case  to  the  Vienna  Dermatological 
Society,  stated  that  "lymphangioma  tuberosum  multiplex" 
is  variously  diagnosed  as  hydradenoma,  hemangio-endo- 
thelioma,  syringocystadenoma,  etc.,  according  to  the  patho- 
genesis  from  gland,  blood  or  lymph  vessel  of  the  skin  as 
determined  by  microscopical  examination." 

1  Crocker  states  that  "these  cases  (multiple  benign  cystic  epithelioma) 
resemble  adenoma  when  abundant.  The  distribution  and  aggregation  may 
be  exactly  like  adenoma  sebaceum,  except  on  the  forehead,  where  the 
growths  are  sparse  in  adenoma  sebaceum,  while  in  the  other  they  are  closely 
grouped  for  the  most  part.  ...  In  a  few  cases  when  the  growths  are 
sparse,  the  microscope  would  have  to  decide  the  question. "  In  writing  of 
lymphangioma  tuberosum  multiplex,  he  states  (p.  978):  "  Kaposi  was  the 
first  to  describe  a  case  of  this  rare  disease  from  Hebra's  clinic,  and  the  name 
he  gave  it  stands  at  the  head  of  this  article  on  the  score  of  priority,  but  not 
as  representing  the  true  nature  of  the  growths,  as  it  is  worse  than  useless 
to  change  it  until  more  general  agreement  is  obtained  regarding  the  pa- 
thology of  this  affection  than  the  farrago  of  synonyms  indicates  to  be  now 
the  case. "  Again  in  a  report  to  the  London  Clinical  Society,  he  pleads 
for  the  separation  of  multiple  benign  cystic  epithelioma  and  lymphangioma 
tuberosum  multiplex,  in  spite  of  their  many  common  characteristics,  and 
in  addition  to  a  number  of  clinical  and  pathological  differences  of  a  relative 
nature,  that  the  former  is  not  hereditary  and  females  predominate  largely 
with  the  latter.  In  my  own  case  of  lymphangioma  tuberosum  multiplex 
herewith  reported,  the  son  inherited  the  condition  from  his  mother,  and  in 


DERMATOLOGICAL  CONGRESS  187 

Dorst  and  Delbanco  report  a  case  of  linear  naevus  which 
they  desire  to  class  with  multiple  benign  cystic  epithelioma, 
and  Gottheil,  among  many  others  in  the  literature,  reports 
an  apparent  case,  from  its  clinical  aspects,  of  naevus  linearis 
or  white  mole  of  the  scalp  as  an  adenoma  sebaceum. 

REPORT  OF  CASES 

G.  C.  G.,  aged  sixty-five,  came  to  my  attention  for  the  first 
time  March  6,  1905.  The  nose  (Plate  vi,  Fig.  i.)  was  the  site  of 
about  seventy-five  small  rounded  or  slightly  pedunculated  new 
growths,  varying  from  a  pin-head  to  a  split-pea  or  slightly 
larger  in  size,  reddish  yellow  in  color,  imbedded  in  the  cutis, 
non-sensitive  to  touch,  and  painless  to  pressure,  and  situated 
mostly  on  each  ala  and  the  root  of  the  nose.  A  number  of 
smaller  lesions  were  distributed  over  the  forehead  in  front  and 
behind  the  ears,  and  over  the  chin.  The  tip  of  the  nose  and 
the  cutaneous  surface  of  the  septum  were  also  the  site  of  the 
lesions.  There  was  no  evidence  of  ulceration  or  active  in- 
flammation. Patient  stated  that  the  lesions  first  manifested 
themselves  when  he  was  about  thirty  years  of  age,  and  that 
they  have  steadily  but  slowly  increased  in  size  and  multiplied 
in  number.  There  was  no  history  of  any  similar  condition 
on  his  father's  side  of  the  family.  His  mother,  to  his  personal 
knowledge,  was  free  from  the  affection,  but  died  before  she 
reached  the  age  of  thirty.  An  uncle  and  an  aunt  on  his 
mother's  side  of  the  family  were  similarly  afflicted,  and  all 
of  his  children,  two  sons,  aged  thirty-four  and  thirty  years 
respectively,  and  two  daughters,  aged  thirty-eight  and  thirty- 
six  years  respectively,  evidence  the  marked  hereditary 
character  of  the  affection.  I  am  able  to  add  my  personal 
confirmation  to  the  inherited  traits  in  three  of  the  children, 
and  they  show  the  same  clinical  and  some  of  the  pathological 
characteristics  of  the  father.  The  affection  began  in  all  of 
the  children  on  the  nose,  when  they  were  from  twenty-five 
to  thirty  years  of  age,  and  although  the  lesions  at  the  present 
time  are  considerably  smaller  in  size,  varying  from  a  pin- 
five  cases  of  multiple  benign  cystic  epithelioma  the  father  shared  the  affec- 
tion with  his  two  sons  and  two  daughters. 


i88  SIXTH  INTERNATIONAL 

head  to  a  good-sized  shot,  they  have  the  same  distribution  as 
that  of  the  father,  except  in  the  second  oldest  daughter  the 
neck  is  also  involved  and  the  lesions  show  the  same  clinical 
and  physical  characteristics.  The  most  striking  feature  of 
the  cases  is  the  fact  that,  while  nearly  all  the  cases  reported 
in  the  literature  have  occurred  in  females,  in  this  instance 
four  males  and  only  three  females  were  afflicted.  These 
cases  from  three  of  whom,  father,  one  son,  and  one  daughter, 
lesions  were  excised  for  histological  examination,  together 
with  five  other  cases  of  multiple  benign  cystic  epithelioma, 
form  the  basis  of  the  pathological  investigation  of  this  report. 
In  one  of  the  five  remaining  cases,  Mr.  B.  P.  M.  (Plate  vi,  Fig.  2), 
aged  sixty-five,  the  lesions  were  multiple,  fifteen  to  twenty  in 
number,  glistening,  translucent,  yellowish  white  in  appearance, 
some  centrally  depressed  and  situated  underneath  each  eye, 
over  the  forehead,  cheeks,  and  chin.  There  was  no  progeny 
in  this  case  and  a  history  of  heredity  was  unobtainable. 

The  microscopic  examination  revealed  an  abundance  of 
interlacing  epithelial  strands  and  cysts.  In  the  remaining 
cases  the  lesions  presented  the  characteristic  clinical  appearance 
of  multiple  benign  cystic  epithelioma,  but  they  were  for  the 
most  part  single  and  discrete,  or  consisted  of  a  small  group 
situated  over  a  limited  area  of  the  face.  All  showed  among 
other  pathological  changes  interlacing  epithelial  strands  and 
colloid  cysts.  To  these  cases  is  added  for  comparative  study 
a  case  of  lymphangioma  tuberosum  multiplex  of  Kaposi  in  P.  A. 
H.,  a  full-blooded  negro,  aged  twenty-five  years,  whose  anterior 
aspect  of  the  thorax,  in  a  triangular  area  bounded  by  the 
nipples  and  the  umbilicus,  is  studded  by  several  hundred 
smooth  rounded  lesions,  varying  from  a  pin-head  to  a  split- 
pea  or  larger  in  size,  slightly  elevated  above  the  level  of  the 
surrounding  skin,  well  imbedded  in  the  cutis,  more  or  less 
oblong  in  outline,  with  the  long  diameter  running  transversely 
with  the  long  axis  of  the  body.  A  group  of  about  fifty  of 
these  lesions  is  situated  above  the  clavicles  and  over  the 
hollow  of  the  neck,  and  four  or  five  small  lesions  are  over  the 
left  scapula.  A  few  lesions  have  undergone  an  apparent 
spontaneous  ulceration,  and  are  the  site  of  faint  depressed 
cicatrices.  The  condition  has  been  present  as  long  as  the 


DERMATOLOGICAL  CONGRESS  189 

patient  can  distinctly  remember;  but  the  lesions  have  slowly 
and  steadily  increased  in  size  and  number.  Subjective  symp- 
toms have  been  uniformly  absent.  Patient,  who  is  married, 
but  without  progeny,  states  that  his  mother  is  similarly  affect- 
ed, but  he  has  no  personal  knowledge  of  any  other  hereditary 
influences.  The  most  striking  clinical  feature  of  this  case, 
is  the  occurrence  of  the  affection  in  the  negro,  the  first  to  be 
recorded  in  that  race,  as  far  as  my  personal  knowledge  per- 
mits me  to  state,  and  its  hereditary  character,  which  is  strongly 
denied  by  some  authors.  For  further  comparative  study,  is 
added  a  case  of  a  rapidly  growing  hairy  pigmented  mole  upon 
the  chin  of  a  young  man,  W.  H.  N.,  aged  twenty-one,  which 
took  on  active  development  at  the  age  of  puberty  and  showed 
upon  histological  examination  some  peculiar  embryonic  fea- 
tures. Finally,  I  wish  to  add  a  case  which  was  diagnosed 
by  its  clinical  features  as  adenoma  sebaceum,  and  presented  as 
such  in  Pusey's  text-book  (Fig.  286,  p.  866,  1907),  Miss  M.  BM 
aged  twenty-seven.  This  case  was  observed  some  seven  years 
ago,  into  which  a  history  of  heredity  was  not  inquired,  and 
a  diagnosis  of  multiple  benign  cystic  epithelioma  was  not 
suspected.  The  patient  has  since  passed  from  my  personal 
observation,  but  personal  recollection  leads  me  to  believe 
that  a  differentiation  of  these  two  affections  in  this  case,  with- 
out a  well  defined  clinical  history  or  a  pathological  examina- 
tion, would  be  difficult  to  effect. 

PATHOLOGY 

The  most  striking,  constant,  and  characteristic  pathological 
change  in  multiple  benign  cystic  epithelioma  (Plate  vii,  Fig.  3), 
is  the  well  recognized  and  oft  described  interlacing  epithelial 
strands,  consisting  of  two  rows  of  large  oval  nucleated  epithelial 
cells  here  and  there  irregularly  dilated  by  an  apparent  en- 
dothelial  proliferation.  These  strands  have  a  very  irregular 
distribution,  for  the  most  parallel  with  or  vertical  to  the 
surface  of  the  skin.  They  possess  many  short  bifurcations,  and 
are  of  short  irregular  lengths  (Plate  vii,  Fig.  4) .  Occasionally 
they  are  short,  and  usually  broad,  and  end  in  three  or  more 
short  tail-like  processes  which  give  them  a  peculiar  stellate 


i9o  SIXTH  INTERNATIONAL 

appearance.  They  are  most  freely  distributed  in  the  upper 
portion  of  the  derma,  near  the  papillae,  but  often  extend  in 
greater  or  less  degree  into  the  lower  depths  of  the  cutis  to  the 
layer  of  subcutaneous  fat.  Their  identity  with  the  ducts 
or  glands  proper  of  embryonic  misplaced  or  imperfectly  de- 
veloped sweat  glands,  has  been  often  considered,  but  is  a 
question  to  which  I  can  add  from  my  personal  observations 
neither  refutation  nor  confirmation.  Sometimes,  in  the  larger, 
longer-standing,  and  more  rapidly  developing  lesions,  I  have 
observed  these  bands  to  be  unusually  broad  and  irregular  in 
outline,  containing  masses  of  actively  proliferating  epithelium, 
with  tongue-like  processes  extending  from  the  borders,  im- 
parting to  them  a  spread-tail-like  appearance.  In  addition 
to  these  strands,  there  are  a  number  of  irregularly  distributed 
round  or  oval  cysts  of  varying  size,  with  an  epithelial  wall  of 
several  layers  of  cells,  with  the  contents  mechanically  removed 
or  consisting  of  more  or  less  concentrically  arranged  stratified 
epithelium  or  colloid  material  (Plate  viii,  Figs.  5 ,  6.)  In  addition 
to  these  two  usually  most  important  changes,  there  is,  as  a 
rule,  a  secondary  change  in  some  other  tissue  element — a 
hyperplasia  of  the  hair  follicles,  connective  tissue,  sebaceous 
or  sudoriferous  glands,  which  is  more  or  less  constant  for  the 
lesions  of  each  case.  These  features  pertain  principally  to 
smaller  lesions;  in  the  larger,  longer  standing,  more  actively 
growing  lesions,  the  original  secondary  hyperplasia  assumes 
the  primary  r61e,  and  the  adenoma  sebaceum,  sudoriparum, 
pili,  etc.,  completely  or  incompletely  overshadows  the  other 
pathological  changes.  In  the  first  group  of  cases,  the  father 
showed  a  marked  hyperplasia  of  the  hair  follicles  in  addition 
to  the  other  characteristic  changes.  These  structures  were 
not  only  markedly  increased  in  depth,  circumference,  and 
stratified  contents,  but  gave  off  very  peculiar-looking,  single, 
occasionally  branched  horn-like  processes.  (This  pathological 
change  has  also  been  noted  by  Fordyce,  p.  467.)  The  most 
striking  pathological  change  in  the  son's  case  was  a  marked 
proliferation  of  the  connective  tissue  from  masses  of  em- 
bryonic-looking cells.  In  the  daughter's  case  the  chief 
secondary  change  was  a  marked  hyperplasia  of  the  sebaceous 
glands,  which  in  the  larger  lesions  resembled  an  adenoma 


DERMATOLOGICAL  CONGRESS  191 

sebaceum.  This  feature  was  also  very  marked  in  one  of  the 
cases  where  the  lesions  were  few  in  number  and  circumscribed 
in  area. 

The  chief  pathological  change  in  the  remaining  cases  is 
a  very  marked  adenomatous  hyperplasia  of  what  apparently 
were  original  sweat  glands,  or  possibly  the  interlacing  strands 
of  epithelial  tissue,  which  characterizes  the  condition.  This 
adenomatous  tissue  is  made  up  of  large,  rounded  irregular 
masses,  consisting  of  two  or  more  rows  of  epithelial  cells, 
arranged  in  columns,  interlacing  and  closely  grouped  with 
more  or  less  polygonal  interstices  of  almost  uniform  size  and 
distribution,  corresponding  to  the  cystic  dilatation  frequently 
observed  in  pathologically  changed  sweat  glands  and  so-called 
cylindromata  cutis.  They  are  surrounded  by  a  thin  mesh- 
work  of  connective  tissue,  extending  almost  to  the  surface 
of  the  skin,  and  situated  for  the  most  part  in  the  upper  layers 
of  the  cutis.  In  many  of  the  cases  the  interstices  are  longi- 
tudinally extended  toward  the  surface,  near  the  centre  of  the 
adenomatous  tissue,  as  if  they  corresponded  or  were  derived 
chiefly  from  the  ducts  of  the  original  glands.  The  cells  showed 
active  mitotic  changes  and  extensive  proliferation,  particu- 
larly around  the  external  portions  of  the  adenoma,  so  that 
the  borders  of  the  larger  lesions  seem  to  be  made  up  of  a  mass 
of  conglomerate  cells,  devoid  of  any  particular  arrangement. 
In  two  of  these  cases,  in  addition  to  this  change  mentioned, 
the  hair  follicles  in  the  immediate  neighborhood  showed  very 
extensive  hypertrophic  changes,  so  that  they  were  many  times 
increased  in  length  and  breadth,  with  their  borders  distinctly 
lobulated.  In  a  few  instances  the  central  portion  of  the  hair 
follicle  corresponding  to  the  site  of  the  original  hair  was  filled 
with  a  mass  of  epithelial  debris,  consisting  of  degenerated 
imperfectly  keratinized  and  stratified  epithelium.  In  others 
this  area  showed  merely  a  clear  space,  indicating  that  the 
soft  material  had  been  mechanically  removed  by  the  knife 
on  sectioning  or  had  fallen  away  in  the  preparation  of  the 
specimen.  The  case  of  lymphangioma  tuberosum  multiplex 
showed  a  very  peculiar  anomalous  condition,  the  analogy 
of  which  I  have  been  unable  to  find  in  the  literature,  with  the 
possible  exception  of  Pollitzer's  case,  reported  in  the  Journal 


192  SIXTH  INTERNATIONAL 

of  Cutaneous  Diseases  (vol.  ix.,  p.  281).  The  lesions  con- 
sisted of  cysts  surrounded  by  a  wall  of  loose  connective  tissue 
and  lined  with  a  number  of  layers  of  epithelial  cells.  The 
larger  cysts  could  not  be  hardened  or  sectioned  with  any 
satisfaction,  the  contents  being  mechanically  removed  with 
the  knife  on  sectioning  or  falling  away  in  the  preparation 
of  the  specimen.  The  smallest  lesions,  pin-head  in  size, 
showed  the  cysts  to  be  filled  with  a  mass  of  degenerated, 
cheesy-looking  epithelial  debris  and  a  large  amount  of  small 
lanugo  hairs,  concentrically  arranged  in  the  form  of  locks. 
The  lesions  bear  pathological  analogy  to  the  dermoid  cyst 
of  the  ovary,  and  in  the  absence  of  any  evidence  of  hair 
follicles  in  the  immediate  neighborhood  of  the  lesions  they 
give  strong  evidence  of  their  embryological  derivation  from 
misplaced  epithelial  tissue  from  the  epiblast.  All  the  lesions 
which  could  be  sectioned  with  any  satisfaction,  and  some 
fifteen  or  twenty  were  examined,  showed  identically  the  same 
change.  None  of  the  lesions  gave  any  evidence  of  having 
been  derived  from  the  endothelium  from  the  lymph  or  blood 
vessels,  and  therefore  this  case  of  lymphangioma  tuberosum 
multiplex  is  unique  in  its  pathological  character  compared 
with  those  already  reported  in  the  literature.  The  case  of 
pigmented  hairy  mole  showed  also  a  very  anomalous  and 
unusual  pathological  condition.  On  sectioning,  it  was  noted 
that  the  knife  encountered  some  extremely  hard  substance, 
which  was  at  first  thought  to  be  calcareous  material.  Two 
microtome  knives  were  practically  ruined  in  obtaining  very 
imperfect  specimens  from  this  case.  While  the  sections  were 
being  cut,  a  number  of  very  small,  poppy-seed-size,  glistening 
bodies  could  be  observed  lying  free  upon  the  specimens  and 
knife-blade,  and  a  number  were  picked  out  from  the  gross 
specimen  by  means  of  a  pair  of  tweezers.  Examination  of 
these  bodies  showed  that  they  consisted  of  rounded  masses 
of  concentrically  arranged  laminated  bone,  which  contained 
typical  Haversian  canals  and  bone  cells.  Under  the  micro- 
scope the  tissue,  in  addition  to  the  characteristic  appearance 
of  the  ordinary  piliferous  pigmented  mole,  showed  a  number 
of  these  bony  nodules  situated  in  the  lower  layers  of  the  cutis 
above  the  subcutaneous  layer  of  connective  tissue  and  fat. 


DERMATOLOGICAL  CONGRESS  193 

The  specimens  also  showed  a  number  of  cavities  from  which 
these  bony  structures  had  been  mechanically  removed  by  the 
knife.  This  case  is,  therefore,  classed  with  a  very  rare  con- 
dition encountered  in  the  literature,  osteoma  cutis,  and  gives 
additional  evidence  of  the  embryological  development  of  some 
of  these  new  growths  from  misplaced  tissue,  which  in  this 
instance  must  have  been  derived  from  the  mesoblast.  (This 
and  the  preceding  case  will  each  form  the  basis  for  a  subse- 
quent report.) 

GENERAL  OBSERVATIONS  AND  DEDUCTIONS 

It  is  evident,  therefore,  that  multiple  benign  cystic  epi- 
thelioma,  in  common  with  lymphangioma  tuberosum  mul- 
tiplex, adenoma  sebaceum,  and  some  of  the  forms  of  linear 
naevus,  present  many  clinical  and  pathological  variations 
within  these  respective  groups,  and  are  sufficiently  common 
to  each  other  to  materially  prevent  a  sharp  differentiation 
of  these  commonly  considered  dermatological  entities.  Their 
development  from  embryonic  misplaced  epithelial  or  en- 
dothelial  tissue  is  almost  universally  conceded  to  be  one  great 
point  of  common  resemblance,  which  should  serve  as  a  strong 
nucleus  around  which  to  gather  other  common  traits  for  the 
elimination  of  any  arbitrary  division  of  these  affections. 
Crocker,  who  has  already  been  quoted  as  an  advocate  for  the 
separation  of  these  affections,  states  (p.  988)  that  adenoma 
sebaceum  is  "  presumably  an  error  of  development  in  the  shape 
of  a  congenital  overgrowth  of  an  adenomatous  character  de- 
veloping from  embryonic  remnants  in  the  skin,  but  in  my  ex- 
perience affecting  all  the  appendages,  and  therefore  really 
a  pilo-sebaceous  hydradenoma. "  Again  he  states:  "The  two 
diseases  (multiple  benign  cystic  epithelioma  and  adenoma 
sebaceum)  resemble  each  other.  Indeed  it  would  not  be 
surprising  if  both  these  affections  would  turn  out  to  be  slightly 
different  clinical  expressions  of  the  same  pathological  process." 
Walter  Pick  states  that  the  clinical  variations  are  marked, 
but  the  histological  picture  is  so  characteristic  and  marked 
as  to  permit  both  the  diagnosis  and  differential  diagnosis.  A 
survey  of  some  of  the  cases  in  the  literature  will  readily  reveal 

VOL.    I. — 13 


I94  SIXTH  INTERNATIONAL 

some  marked  clinical  and  pathological  variations.  Brooke's, 
Fordyce's,  Fellander's,  and  Balzer's  cases  resembled  clinically 
adenoma  sebaceum.  Derivation  from  the  sweat  glands  was 
noted  in  the  cases  of  Brooke,  Darier,  and  Torok;  from  se- 
baceous glands,  by  Pick  and  Balzer;  from  all  the  various 
structures,  by  White,  Fordyce,  Wolters,  and  Fellander;  from 
hair  follicles,  by  Jarisch;  from  the  epidermis,  by  Csillag. 
Krzysztalowicz  states  that  the  pathology  of  adenoma  seba- 
ceum consists  of  a  proliferation  of  all  organs  and  tissues 
of  the  skin  in  the  most  varied  combination.  He  objects  to 
its  nomenclature  and,  together  with  Leredde,  Pezzoli,  Jadas- 
sohn,  Dohi,  Holier,  Winkler,  and  many  others,  classes  the 
affection  with  the  naevi.  Reitmann  reports  a  case  of  adenoma 
sebaceum  in  which  the  chief  pathological  change  was  a  con- 
nective tissue  hypertrophy  poor  in  cells,  rich  in  vessels,  to 
which  he  attributed  an  embryonic  development.  Thin  re- 
ports a  case  that  was  clinically  a  lymphangioma  tuberosum 
multiplex,  in  which  the  lesions  were  derived  from  the  normal 
sweat  glands,  which  showed  endothelial  proliferation  and 
cystic  dilatation.  Neumann,  Blaschko,  Unna,  Philippson, 
Quinquaud,  Torok,  share  this  same  view  in  regard  to  the 
origin  of  their  cases  of  lymphangioma  tuberosum  multiplex. 
Kaposi,  Lesser,  Kromayer,  attribute  the  origin  of  their  cases 
to  lymph  vessels;  Wolters,  Guth,  Elsching,  Jarisch,  to  blood 
vessels;  and  Jacquet  and  Darier,  to  misplaced  embryonic 
epithelial  cells.  The  subject  cannot  be  dismissed  without 
consideration  of  the  relation  of  these  cases  to  malignancy. 
This  feature  has  already  received  careful  clinical  impress 
at  the  hands  of  White  and  Jarisch  in  the  presentation  of  cases 
with  ulcerative  changes  not  far  removed  from  those  observed 
in  malignancy,  and  with  the  comment  that  these  cases  have 
been  observed  and  recognized  too  short  a  time  to  permit  as 
yet  a  proper  estimate  of  their  terminal  course.  Fordyce  has 
presented  a  very  careful  pathological  report  of  the  affection  and 
has  recorded  the  striking  analogy  which  exists  in  the  pathology 
of  these  two  affections.  My  personal  observations  in  the 
pathology  of  multiple  benign  cystic  epithelioma  are  a  con- 
firmation of  those  of  Fordyce,  and  I  am  frank  to  state  that 
the  advanced  lesions  of  multiple  benign  cystic  epithelioma 


DERMATOLOGICAL  CONGRESS  195 

not  only  show  evidence  of  malignant  change,  but  I  have 
been  able  to  find  a  parallel  for  them  in  every  pathological 
phase  and  form  in  the  clinical  lesions  of  early  or  pre-malignant 
change  in  the  skin.  This  leads  me  to  believe  that  malignancy, 
aside  from  prolonged  irritating  influences,  has  its  focus  in 
embryonic  misplaced  tissue,  which  is  further  confirmed  by 
the  oft-observed  multiple  excoriations,  keratoses,  and  second- 
ary ulcerations  in  malignancy  of  the  skin,  which  are  prone  to 
take  on  the  same  malignant  changes  as  the  primary  lesions, 
particularly  if  the  latter  are  removed  or  favorably  influenced 
by  treatment. 

CONCLUSIONS 

1.  Multiple    benign    cystic    epithelioma    presents    many 
clinical  and  pathological  variations  common  to  those  of  ade- 
noma  sebaceum,   lymphangioma  tuberosum  multiplex,   and 
some  of  the  forms  of  naevus  with  discrete  bilaterally  distributed 
lesions. 

2.  All  these  enumerated  affections  present  a  common 
pathogenesis    from    misplaced    embryonic    tissue;    their    in- 
dividual pathology  and  clinical  characteristics  are  exceedingly 
varied,  but  common  to  each  other. 

3.  The  terms  multiple  benign  cystic  epithelioma,  lym- 
phangioma tuberosum  multiplex,  and  adenoma  sebaceum,  or 
their  numerous  and  varied  synonyms,  are  not  appropriate 
to  the  clinical  and  pathological  character  of  these  affections. 
In  view  of  their  common  pathogenesis  and  the  close  alliance 
of  many  of  their  clinical  and  pathological   characteristics, 
these  affections,  to  avoid  any  arbitrary  reduplication  and  unne- 
cessary redundancy  in  nomenclature,  should  be  conveniently 
grouped  into  one  class. 

4.  The  pathology  of  each  of  these  so-termed  separate 
types  of  dermatological  new-growth  embraces  the  hypertrophy 
of  all  the  glandular  elements  and  all  the  tissues  of  the  skin 
in  the  most  varied  form  and  combination,  and  precludes  the 
use  of  pathological  descriptive  terms  in  the  nomenclature.     In 
view  of  their  common  embryonic  derivation,  and  the  multiple 
discrete  papular  disseminated  character  of  the  lesions,   an 


196  SIXTH  INTERNATIONAL 

appropriate  and  generic  nomenclature  would  be  "Multiple 
Disseminated  Embryonic  Lichenoid  Eruptions  of  the  Skin." 
5.  Careful  consideration  should  be  given  to  the  analogy 
which  this  class  of  affections  bears  to  the  clinical  and  patholog- 
ical changes  of  early  malignancy,  and  to  what  extent  malig- 
nancy owes  its  origin  to  lesions  whose  presence  are  due  to  the 
errors  of  embryonic  development. 

REFERENCES 

1.  BALZER  and  MENETRIER.     Arch,  de  Physiolog.,  1885,  vol.  6. 

2.  BESNIER.     Path,  et  Trait,  des  Malad.  de   la  Peau,  Kaposi,  1891, 
vol.  ii.,  p.  368. 

3.  BiRCH-HmscHFELD.     Allge.  Path.  Anatomic,  1890. 

4.  BLASCHKO.     Berlin  Dermatolog.  Society,  June  14,  1898.     Monatsh. 
f.  prakt.  Derm.,  vol.  xxvii.,  p.  175. 

5.  BROOKE.     Brit.  Jour.  Dermatol.,  1892,  vol.  4,  p.  269. 

6.  CROCKER.     Diseases  of  the  Skin,  third  edition,  p.  988. 

7.  CROCKER.     London    Clinical    Society,    Transactions,  1899,  vol.    32, 

P-  151- 

8.  CSILLAG.     Arch.  f.  Derm.  u.  Syph.,  vol.  72,  p.  175. 

9.  DORST  and  DELBANCO.     Monatsh.  f.  prakt.  Derm.,  vol.  xxxiii. 

10.  FELLANDER.     Arch.  f.  Derm.  u.  Syph.,  vol.  74,  p.  203. 

11.  FORDYCE.     Jour.  Cutan.  and  G.-U.  Diseases,  1892,  vol.  x.,  pp.  467 
and  473. 

12.  Fox.     Brit.  Jour.  Dermatol.,  1897,  p.  230,  case  report. 

13.  GASSMAN.     Arch.  f.  Derm.  u.  Syph.,  1901,  vol.  58,  p.  177. 

14.  GOTTHEIL.     "Adenoma  Sebaceum,"  Jour.  Amer.  Med.  Assn.,  1901, 
vol.  xxxvii.,  p.  176. 

15.  GUTH.     Festsch.  Kaposi,  Arch.  f.  Derm.  u.  Syph.,  1900. 

16.  HALLOPEAU.     Annal.  de  Dermatol.,  1894,  vol.  xxviii.. 

17.  HALLOPEAU.     Annal.  de  Dermatol.,  1890,  p.  872. 

18.  JACQUET.     Cong.  Int.  de  Derm,  et  de  Syph.,  Compt.  Rend.,   1889, 
p.  416. 

19.  JACQUET  and  DARIER.     Annal.  de  Dermatol.,   1887. 

20.  JAMIESON.     Brit.  Jour.  Dermatol.,  1893,  vol.  v.,  p.  138. 

21.  JARISCH.     Arch.  f.  Derm.  u.  Syph.,  1894,  vol.  28,  p.  163. 

22.  KAPOSI  and  BIESIADECKI.     Hebra-Kaposi,    Path.  Anatom.  Hand- 
buch,  1872. 

23.  KREIBICH.     Arch.  f.  Derm.  u.  Syph.,  vol.  70,  p.  3. 

24.  KRZYSZTALOWICZ.     Monatsh.  f.  prakt.  Derm.,  1907,  vol.  xlv.,  July  i. 

25.  LESSER  and  BENEKE.     Virch.  Arch.,  vol.  cxxiii.,  1891. 

26.  NEUMANN.     Arch.  f.  Derm.  u.  Syph.,  vol.  54,  p.  3,  1900. 

27.  PERRY.     Int.  Atlas,  R.  F.  D.,  vol.  iii.,  pi.  9. 

28.  PHILLIPSON.     Brit.  Jour.  Derm.,  1891,  vol.  3,  p.  35. 

29.  PICK.     Arch.  f.  Derm.  u.  Syph.,  1901,  vol.  58,  pp.  201  and  215. 

30.  POLLITZER.     Jour.  Cutan.  and  G.-U.  Diseases, "1891,  vol.  ix.,  p. 281. 

31.  POOR.     Monatsh.  /.  prakt.  Derm.,  vol.  40. 

32.  PRINGLE.     Brit.  Jour.  Dermatol.,   1890,  p.   i. 


PLATE  VI— To  Illustrate  Dr.  M.  L.  Heidingsfeld's  Article. 


7 


FIG.  1. 


PLATE  VII— To  Illustrate  Dr.  M.  L.  Heidingsfeld's  Article. 


v    $ 


FIG.  3. 


FIG.  4. 


PLATE  VIII— To  Illustrate  Dr.  M.  L.  Heidingsfeld's  Article. 


FIG.  5. 


FIG.  6. 


DERMATOLOGICAL  CONGRESS  197 

33.  QUINQUAUD.     Int.  Dermatol.  Congress,  Paris,  Compt.  Rend.,  1889. 

34.  REITMANN.     Arch.  f.  Derm.  u.  Syph.,  vol.  83,  p.  177. 

35.  T6R6K.     Monatsh.  f.  prakt.  Derm.,  1889,  vol.  viii.,  p.  116. 

36.  THIERSCH.     Arch.  f.  Derm.  u.  Syph.,  vol.  69,  p.  3. 

37.  WHITE.     Jour.  Cutan.  and  G.-U.  Diseases,  1894,  p.  477. 

38.  WILHELM.     (Vienna  Derm.  Soc.,  Feb.  8,  1905),  Arch.  f.  Derm.  u. 
Syph.,  vol.  76,  p.  417. 

39.  WOLTERS.     Arch.  f.  Derm.  u.  Syph.,  1901,  pp.  89  and  197. 

DESCRIPTION  OF  PLATES. 

Plate  vi.,  Fig.  i. — Multiple  benign  cystic  epithelioma.  A  maternal  aunt 
and  uncle  two  sons  and  two  daughters  similarly  affected. 
The  lesions  developed  in  all  the  cases  at  the  age  of 
twenty -five  to  thirty  years,  and  are  distributed  mostly 
on  the  nose.  (Clinical  type  of  the  first  class  of  cases.) 
"  Fig.  2 . — Multiple  benign  cystic  epithelioma.  Showing  a  number  of 
glistening,  translucent  lesions,  some  centrally  de- 
pressed. (Clinical  type  of  the  second  class  of  cases.) 

Plate  vii.,  Fig.  3. — Multiple  benign  cystic  epithelioma,  showing  many  short 
interlacing  epithelial  strands  in  the  upper  layer  of  the 
cutis,  with  a  distribution  for  the  most  part  parallel  and 
vertical  to  the  surface  of  the  skin.  The  specimen  also 
shows  a  cyst  filled  with  colloid  substance,  several  with- 
out contents,  and  a  few  remnants  of  sebaceous  glands. 
This  is  the  most  common  and  striking  form  of  patho- 
logical change  in  multiple  benign  cystic  epithelioma, 
but  is  .not  constant  enough  to  possess  characteristic 
and  pathognomonic  value. 

Fig.  4. — Ephitelial  strands  of  Fig.  3,  more  strongly  magnified, 
showing  their  parallel  and  vertical  distribution,  angular 
outline,  bifurcating  and  stellate  character.  The  strands 
consist  of  two  or  more  rows  of  epithelial  cells.  At  the 
bottom,  the  wall  of  an  empty  cyst  can  be  readily  seen. 

Plate  viii.,  Fig.  5. — Chief  pathologic  change  in  the  lesions  obtained  from  the 
father  in  the  first  group  of  cases.  Hair  follicle  in  cir- 
cumference and  stratified  contents,  giving  off  peculiar- 
looking  horn-like  processes,  single  or  branched  in 
character. 

Fig.  6. — Showing  characteristic  cysts  and  adenoma  of  sebaceous 
glands. 

Discussion 

DR.  M.  B.  HARTZELL,  of  Philadelphia,  said  the  affection  which 
Dr.  Heidingsfeld  had  described  invariably  has  its  origin  in  the 
hair  follicles.  There  was  more  or  less  similarity  between  these 
cases  and  those  described  as  syringocystoma,  and  the  speaker 
said  that  in  his  opinion  they  were  both  varieties  of  one  and  the 
same  disease.  He  thought  it  could  be  shown — in  fact,  he  had 
sections  which  showed  beyond  the  shadow  of  a  doubt — that  the 


198  SIXTH  INTERNATIONAL 

long,  slender  duct-like  processes  in  the  latter  took  their  origin 
from  the  hair  follicles,  and  that  this  could  be  demonstrated  in  the 
vast  majority  of  cases.  No  one  had  succeeded  in  showing  any 
connection  between  these  long  slender  duct-like  tracts  and  the 
sweat  glands.  Practically,  these  two  processes,  which  clinically 
were  much  alike  but  which  showed  some  pathological  differences, 
were  examples  of  the  same  disease,  and  were  due  to  an  abnormal 
increase  in  the  epithelium,  in  both  instances  having  their  origin 
in  the  hair  follicles. 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  said  it  seemed  to  him  rather 
important  to  preserve  the  distinction  between  the  two  conditions 
on  clinical  grounds.  In  one  we  had  a  certain  syndrome  which 
might  be  called  the  Perry-Brooke-Fordyce  type,  chiefly  in  women, 
with  discrete  but  grouped,  symmetrical  lesions  occurring  on  the 
face  and  temples,  at  the  root  of  the  nose,  and  on  the  back,  which 
clinically,  it  seemed  to  him,  were  very  different  from  the  larger 
lesions  so  often  seen  on  the  trunk,  neither  grouped  nor  symmetrical, 
the  hydrade'nome  £ruptif  of  Jacquet  Darier,  probably  the  same 
thing  as  lymphangioma  tuberosum  multiplex. 


OBSERVATIONS    ON    SKIN    DISEASES    IN    THE 

NEGRO 

BY  DR.  HOWARD  Fox,  OF  NEW  YORK 

In  presenting  to  you  the  subject  of  skin  diseases  in  the 
negro,  I  have  a  double  excuse  to  offer.  I  feel  in  the  first  place 
that  this  branch  of  dermatology  has  long  been  sorely  neglected. 
In  the  second  place  I  have  hoped  that,  as  the  opportunities 
to  observe  negroes  abroad  are  very  limited,  this  subject  might 
prove  of  interest  to  our  foreign  visitors. 

Valuable  statistics  upon  five  hundred  and  fifty-six  cases 
of  skin  disease  in  the  negro  have  been  contributed  by  Dr. 
Isadore  Dyer  of  New  Orleans.  With  the  exception,  however, 
of  Morison  who  compared  five  hundred  cases  of  skin  diseases 
occurring  in  negroes  with  an  equal  number  of  whites,  no  one 
has  attempted  a  statistical  comparison  of  skin  diseases  affect- 
ing the  two  races.  Owing  to  the  kindness  of  Dr.  Gilchrist  of 
Baltimore,  and  Dr.  Carmichael  of  Washington,  I  have  been 
enabled  to  make  a  comparative  study  of  four  thousand  four 


DERMATOLOGICAL  CONGRESS  199 

hundred  cases,  half  of  them  in  the  negro  and  half  in  the 
white  race. 

It  would  perhaps  have  been  more  fitting  if  the  subject 
had  been  treated  by  one  of  my  southern  colleagues  whose 
opportunities  for  studying  negroes  are  much  greater  than  any 
we  have  in  New  York.  My  sources  of  information,  however, 
include  a  correspondence  with  physicians  in  all  of  the  South 
Atlantic  and  South  Central  States,  with  the  exception  of 
Delaware,  Indian  Territory,  and  Oklahoma,  making  a  total  of 
fifteen  States,  including  Missouri.  In  this  area  are  to  be  found 
approximately  nine-tenths  of  the  negroes  of  Continental 
United  States. 

My  personal  experience  has  been  confined  chiefly  to  the 
Vanderbilt  Clinic  in  the  service  of  my  father,  Dr.  George 
Henry  Fox.  As  there  is  a  considerable  negro  population  in 
the  neighborhood  of  the  clinic,  very  fair  opportunities  for 
observing  skin  diseases  in  this  race  have  been  presented.  The 
majority  of  cases  in  my  exhibition  of  photographs  are  from 
the  Vanderbilt  Clinic. 

My  statistics  are  partly  from  the  Central  Dispensary  of 
Washington,  and  partly  from  the  Johns  Hopkins  Dispensary 
of  Baltimore.  The  objection  that  these  statistics  are  from 
practically  one  section  of  the  South,  Baltimore  and  Washing- 
ton being  neighboring  cities,  is  a  valid  one.  I  should  like  to 
have  obtained  records  from  several  widely  separated  regions 
of  the  South,  but  it  was  not  possible  for  me  to  do  so.1 

Though  the  literature  pertaining  to  skin  diseases  in  the 
negro  is  very  limited,  I  have  found  especially  valuable  in- 
formation in  the  writings  of  Atkinson,  Morison,  Dyer,  Corson, 
Mat  as,  and  Rufz. 

The  history  of  our  colored  population  dates  from  1619, 

1  The  statistics  from  the  Central  Dispensary  include  one  thousand  two 
hundred  cases  of  whites  taken  from  ten  consecutive  years,  1897  to  1906  in- 
clusive, and  a  similar  number  of  cases  of  blacks  for  eight  consecutive  years, 
the  blacks  at  this  dispensary  being  numerically  greater.  The  remaining  one 
thousand  cases  of  each  race  are  from  the  Johns  Hopkins  Dispensary.  At  the 
latter  clinic  owing  to  the  disproportion  in  favor  of  the  whites,  the  records 
of  one  year  February,  1906  to  1907  only,  were  required  to  furnish  one 
thousand  consecutive  white  cases,  whereas  six  years  (November,  1901  to 
February,  1907)  were  required  to  supply  an  equal  number  of  cases  in  the 
negro. 


200  SIXTH  INTERNATIONAL 

when  the  first  slaves  were  brought  to  Virginia.  In  1776  more 
than  300,000  slaves  had  been  brought  to  the  colonies,  and  at 
the  end  of  the  Civil  War  there  were  4,000,000  of  negroes  in 
the  United  States.  According  to  the  twelfth  census,  that  of  1 900, 
there  were  approximately  8,840,000  negroes  in  Continental 
United  States,  out  of  a  total  population  of  nearly  85,000,000. 
It  seems  to  me  that  this  vast  number  of  negroes  affecting  by  its 
presence  the  statistics  of  economics,  social  and  political  sci- 
ence, must  also  have  its  influence  on  medical  statistics  and 
should  be  worthy  of  study  in  every  branch  of  our  science. 

Although  at  present  the  American  negro  represents  a 
fusion  of  numerous  African  tribes,  it  is  still  thought  possible 
by  some  to  distinguish  certain  subtypes.  According  to  Otken, 
"  We  have  in  the  United  States  the  Guinea  negroes,  Yoloffs, 
and  Caffres.  To  these  must  be  added  those  in  whose  veins 
flow  one-half,  three-fourths,  or  seven-eighths  white  blood, 
or  the  mulattoes,  quadroons,  and  octoroons.  (The  last  three 
are  designated  usually  by  the  common  title  mulatto.)  The 
Guinea  negroes  constitute  an  overwhelming  majority.  They 
are  characterized  by  their  woolly  hair  and  black  skin,  thick 
lips,  broad  flat  nose,  prognathous  jaws,  receding  forehead, 
slender  limbs,  and  massive  feet.  The  Yoloffs  in  addition  to 
woolly  hair  and  jet  black  skin,  possess  a  fine  form  and  strictly 
European  features.  The  Caffres  have  woolly  hair,  blackish- 
brown  complexion,  and  have  a  fine  form  and  features.  The 
Yoloffs  and  Caffres  may  constitute  from  five  to  ten  per  cent, 
of  the  pure  African  race." 

Interesting  as  the  study  of  the  various  types  of  American 
negroes  may  be,  it  is  of  more  practical  importance  for  the 
purpose  of  this  inquiry  to  obtain  some  idea  of  the  numbers 
of  mulattoes  in  the  Southern  States,  the  region  from  which 
my  statistics  were  obtained.  It  was  the  conclusion  of  four 
independent  groups  of  enumerators  of  the  twelfth  census, 
that  between  one-ninth  and  one-sixth  of  the  negroes  in  Con- 
tinental United  States  showed  an  admixture  of  white  blood. 
The  greatest  number  of  mulattoes  were  found  in  regions  where 
the  proportion  of  blacks  to  whites  was  small  and  the  smallest 
number  where  the  proportion  of  blacks  to  whites  was  large. 
This  is  well  illustrated  by  the  report  of  the  eleventh  census, 


DERMATOLOGICAL  CONGRESS  201 

showing  thirteen  per  cent,  of  mulattoes  in  the  South  Atlantic 
States,  twenty-three  per  cent,  in  the  North  Atlantic  and 
sixty-two  per  cent,  in  the  Western  States.  For  the  purpose 
of  enumeration,  all  persons  were  classed  as  negroes  who  were 
considered  to  be  such  in  the  communities  in  which  they  lived. 
The  same  census  showed  fifteen  and  nine-tenths  per  cent,  of 
mulattoes  for  the  State  of  Maryland,  and  the  rather  high 
figure  of  twenty-six  and  two-tenths  per  cent,  for  the  District 
of  Columbia,  from  which  a  considerable  part  of  my  statistics 
were  obtained. 

It  is  the  question  of  mulattoes  that  presents  one  of  the 
great  difficulties  of  a  statistical  inquiry  like  the  present  one. 
If  my  study  could  have  been  confined  solely  to  full-blooded 
negroes,  it  would  unquestionably  have  been  of  greater  scien- 
tific value.  Although  my  statistical  tables  include  without 
discrimination  all  "colored"  persons  from  the  octoroon  to  the 
full-blooded  blacks,  I  have  obtained,  however,  from  my  corre- 
spondents, some  valuable  information  relating  solely  to  the 
full-blooded  negroes. 

A  very  obvious  difficulty  to  the  study  of  skin  diseases  in 
negroes  is  presented  by  their  deeply  pigmented  skin.  On  this  ac- 
count a  diagnosis  of  the  exanthemata,  rosacea,  in  its  early  stages 
the  various  forms  of  erythema  and  purpura,  and  certain  pig- 
mentary affections  is  often  difficult  and  at  times  impossible. 

Another  difficulty  is  presented  by  the  unreliability  of 
statements  of  many  negro  patients.  The  following  de- 
scription of  Dr.  Grindon  of  St.  Louis,  truthfully  represents 
the  dense  ignorance  of  a  considerable  portion  of  our  negro 
population.  "Negroes  rarely  know  their  ages,  and  in  stating 
them  are  often  as  much  as  twenty  years  out  of  the  way. 
Women  are  often  'about  twenty'  until  they  cease  bearing 
children.  Soon  after  that  they  are  'about  seventy.'  After 
some  ten  years  of  this  they  are  'over  a  hundred.' 

In  the  effort  to  determine  the  relative  frequency  in  general 
of  skin  diseases  in  the  two  races,  a  further  difficulty  is  en- 
countered by  the  fact  that  negroes  do  not  seem  to  patronize 
our  public  clinics  as  often  as  whites.  Their  numbers  in  dis- 
pensary practice,  according  to  Drs.  Grindon,  Dyer,  and  Rosen- 
thai,  are  proportionately  less  than  those  of  the  whites.  They 


202  SIXTH  INTERNATIONAL 

are  only  apt  to  seek  treatment  for  affections  of  the  skin  which 
cause  positive  annoyance  or  pain.  Their  smaller  attendance 
at  our  clinics  may  be  due,  as  Dr.  Grindon  suggests,  to  the  care- 
less habits  of  their  race  and  to  their  widespread  though  lessen- 
ing prejudice  against  medical  schools,  and  all  that  pertains 
thereto.  In  order  to  obtain  positive  proof  that  skin  diseases 
are  less  prevalent  in  the  negroes  than  in  the  whites,  it 
would  be  necessary  to  ascertain  the  total  white  and  black 
population  of  a  community,  and  to  compare  this  with  the 
total  [number  of  applicants  at  dermatological  and  at  all 
other  combined  clinics.  Though  I  have  not  undertaken 
such  a  heroic  task,  my  conviction  is  firm  that  negroes 
do  not  suffer  from  skin  diseases  in  general,  as  often  as 
whites. 

Do  negroes  suffer  less  severely  than  whites  ?  is  a  question 
which  naturally  follows.  It  will  be  one  of  the  objects  of  this 
paper  to  attempt  to  answer  this  question  in  the  affirmative 
and  to  show  that  most  diseases  of  the  skin  affect  the  negro 
less  severely  than  they  do  the  whites.  This  proposition,  if 
true,  will  seem  the  more  unusual  in  view  of  the  well-known 
susceptibility  of  the  negro  to  a  large  number  of  constitutional 
and  other  diseases. 

That  the  American  negro  at  present  suffers  more  from 
disease  in  general  than  the  white  man  is  shown  by  the  reports 
of  the  last  census.  The  mortality  in  the  registration  area 
for  the  negro  was  found  to  be  thirty  and  two-tenths  per  cent., 
while  that  of  the  whites  was  only  twenty-seven  and  three- 
tenths  per  cent.,  or  less  than  one  half  as  great.  Furthermore, 
according  to  Frederick  Hoffmann,  a  statistician  of  authority, 
the  mortality  among  the  negroes  is  on  the  increase,  whereas 
that  of  the  whites  is  diminishing.  The  same  writer  states 
that  the  colored  race  is  subject  to  a  greater  mortality  from 
all  diseases  of  infancy,  consumption  at  all  ages,  pneumonia, 
venereal  diseases,  and  even  malaria. 

Before  attempting  to  analyze  the  more  important  skin 
diseases  in  the  two  races,  it  may  be  well  to  remind  you  of  cer- 
tain anatomical  differences  in  the  skin,  to  which  doubtless 
some  of  the  disproportion  in  frequency  and  severity  of  different 
skin  affections  is  due.  It  is  well  known  that  the  characteristic 


DERMATOLOGICAL  CONGRESS  203 

pigmentation  of  the  negro  skin  is  not  present  at  birth.  In 
speaking  of  negro  babies,  Brodnax  says,  "They  are  not  of  the 
clear  pink  of  the  pure  Caucasian,  but  present  a  color  of  tallow, 
a  muddy  white,  not  colored  or  tinted.  In  cases  in  which 
both  parents  are  true  blacks,  the  deepening  of  the  color  is  seen 
in  a  few  hours,  and  in  a  couple  of  weeks,  the  skin  is  quite 
dark,  attaining  its  full  depth  in  about  two  months. "  Simonot 
states  that  the  negro  acquires  the  maximum  of  his  color  at 
puberty,  and  that  old  age  leads  frequently  to  a  certain  de- 
coloration of  the  skin.  The  light  color  of  the  palms  and  soles, 
lateral  borders  of  the  fingers  and  portions  of  the  mucous 
membrane  of  the  mouth,  prepuce,  and  vulva,  approaches 
closely  to  that  of  the  white.  The  deeper  pigmentation  is 
seen  upon  the  posterior  portion  of  the  trunk,  shoulders, 
loins,  buttocks,  and  upper  portions  of  the  thighs.  The 
difference  in  pigmentation  is  simply  one  of  amount  and 
distribution. 

The  entire  skin  of  the  negro,  especially  the  derma,  is 
thicker  than  that  of  the  white.  This  is  also  true  of  the  sub- 
cutaneous tissue  as  exemplified  by  the  characteristic  thick 
lips  of  the  negro. 

It  is  in  the  appendages  of  the  skin  that  some  of  the  racial 
differences  are  most  striking.  The  glandular  system  is  cer- 
tainly more  highly  developed  in  the  negro.  The  greater 
production  of  sweat  is  largely  responsible  for  the  suppleness 
of  the  negro  skin  and  aids  him  to  endure  the  intense  heat 
of  the  tropics.  The  sebaceous  secretion  gives  to  the  skin 
its  shiny  aspect  and  characteristic  odor. 

The  short  kinky  hair  next  to  his  dark  skin  is  the  negro's 
most  characteristic  feature.  To  the  slight  development  of 
lanugo  hair  is  largely  due  the  soft  velvety  feeling  of  the  negro 
skin.  The  lessened  hairy  development  is  also  seen  in  the  hair 
of  the  beard,  axilla,  and  pubes.  Finally,  it  should  be  men- 
tioned that  the  negro  is  decidedly  less  susceptible  to  pain  than 
the  white  man. 

I  should  like  to  begin  my  analysis  with  a  consideration 
of  the  effect  upon  the  negro  skin  of  external  irritants.  Among 
the  latter  should  be  included  the  sun's  rays  and  other  forms 
of  radiant  energy,  as  well  as  various  irritants  of  vegetable 


2o4  SIXTH  INTERNATIONAL 

and  mineral  origin.  There  seems  no  doubt  that  to  most 
forms  of  external  irritation,  the  negro  skin  is  decidedly  less 
susceptible  than  that  of  the  white.  A  hot  sun  which  will 
severely  burn  the  white  skin  will  have  no  effect  upon  that 
of  the  negro.  Dr.  Boyd  of  Jacksonville  writes  me  that  he 
considers  it  very  difficult  to  "  blister  a  pure  negro. "  It  would 
be  interesting  to  know  whether  the  reaction  to  the  X-ray 
was  slower  in  making  its  appearance,  or  milder  in  the  negro 
than  in  the  white.  My  experience  in  treating  negroes  with 
the  X-ray  has  been  very  limited,  and  I  have  unfortunately 
not  obtained  expressions  of  opinion  upon  this  subject  from 
my  correspondents.  My  statistics  for  cases  designated  as 
dermatitis  and  dermatitis  venenata  (affections  due  to  ex- 
ternal irritants),  give  a  total  of  one  hundred  and  thirteen 
whites  to  fifty-six  blacks,  or  just  twice  as  many  whites  as 
blacks. 

An  example  of  lessened  susceptibility  to  vegetable  irritants 
is  given  by  my  statistics  for  poison  by  the  rhus  toxicodendron, 
which  showed  twenty-two  cases  in  the  white  against  eight  in 
the  black.  While  these  figures  show  a  much  greater  prevalence 
of  ivy  poisoning  in  the  white,  the  disproportion  in  my  opinion 
would  have  been  much  greater  in  a  comparison  of  whites 
with  full-blooded  negroes.  In  replying  to  the  question,  "Is 
the  negro  immune  to  ivy  poisoning?"  the  answer,  "I  have 
never  seen  a  case,"  or  "I  have  never  seen  a  case  in  a  full- 
blooded  negro,"  has  been  given  by  a  majority  of  my  corre- 
spondents. Many  add  that  they  frequently  see  ivy  poisoning 
in  the  white  race.  Four  have  answered  "no,"  without  any 
further  qualification.  Dr.  Whitehead  of  Atlanta  and  Dr. 
Engman  of  St.  Louis,  both  write  that  they  have  seen  some 
severe  cases.  Others  answer,  "almost  immune,"  or  "nearly 
so."  Dr.  Strobel  of  Baltimore,  answers  "not  immune,  but 
cases  very  uncommon,  so  much  so  that  one  severe  case  I  saw 
in  a  negro  boy  impressed  me. "  Dr.  Bernard  Wolff  of  Atlanta, 
writes  me  of  a  railroad  contractor  who  employed  one  hundred 
and  fifty  negroes  in  a  region  where  poison  ivy  abounded.  Not 
one  of  these  men  suffered  from  ivy  poisoning.  In  the  sta- 
tistics of  Morison,  and  in  those  of  Dyer,  no  cases  of  ivy 
poisoning  in  the  negro  are  recorded. 


DERMATOLOGICAL  CONGRESS 


205 


TABLE  I 
ABSCESS — FROST-BITE 


WHITES 

NEGROES 

Disease 

Clinic 

Total 
Patients 

Cases 

Percent- 

Total 
Patients 

Cases 

Percent- 

Applying 

age 

Applying 

age 

Abscess, 

carbuncle, 

furuncle  , 

furunculo- 

sis,  phleg- 

Surgi- 

mon 

cal 

4072 

75° 

.184 

6873 

1056 

•153 

Frost-bite 

Surgi- 

and   chil- 

cal 

blains 

and 

Skin 

6272 

26 

.00414 

9°73 

78 

.00859 

Statistics  compiled  from  Central  Dispensary  of  Washington,  D.  C.,  for 
nine  consecutive  years,  1898  to  1906. 

In  considering  the  probable  effect  of  heat  and  cold  upon 
the  negro  skin,  it  would  be  natural  to  expect  that  eruptions 
due  to  heat  would  be  less  common  in  the  negro,  and  that  frost- 
bite and  chilblains  the  result  of  cold  would  be  more  common. 
As  a  matter  of  fact,  this  is  rather  strikingly  shown  by  my 
statistics.  There  were  twelve  cases  of  miliaria  and  heat  rash 
in  the  white  and  only  two  in  the  black.  On  the  other  hand 
only  one  white  as  against  fourteen  blacks  appears  under  the 
heading  of  frost-bite  and  chilblains.  The  latter  figures  must, 
however,  be  modified,  as  the  majority  of  cases  of  frost-bite 
at  the  Central  Dispensary,  at  least,  were  treated  in  the  surgical 
clinic.  I  have,  therefore,  tabulated  the  cases  of  frost-bite 
and  chilblains  that  applied  at  the  latter  clinic  during  nine 
years.  Added  to  the  other  cases,  a  total  of  twenty-six  white 
and  seventy-eight  blacks  is  given,  or  when  the  total  number 
of  patients  is  considered,  the  proportion  of  blacks  to  whites 
was  two  to  one.  Morison  considers  chilblains  a  common  dis- 
ease in  the  negro,  his  statistics  giving  ten  cases  in  the  black 
and  three  in  the  white.  If  chilblains  are  more  prevalent  in 
the  negro,  and  I  believe  that  they  are,  a  reasonable  explanation 
would  be  that  negroes  are  more  exposed,  and  more  poorly 
clad  and  housed  than  their  more  fortunate  white  brethren. 

In  an  effort  to  compare  the  susceptibility  of  the  two  races 


206  SIXTH  INTERNATIONAL 

to  the  ordinary  pus  germs,  the  different  varieties  of  the  staphy- 
lococci,  I  have  tabulated  cases  designated  as  phlegmon,  ab- 
scess (tuberculous,  ischio-rectal  and  alveolar  being  excluded), 
furuncle,  furunculosis,  and  carbuncle.  My  figures,  which  are 
taken  from  the  surgical  clinic  of  the  Central  Dispensary  for 
nine  years,  show  seven  hundred  and  fifty  whites,  and  one 
thousand  and  fifty-six  blacks,  or  in  proportion  to  the  attend- 
ance of  the  two  races,  eighteen  per  cent,  for  the  whites  and 
fifteen  for  the  blacks.  A  similar  table  of  Matas  containing 
nearly  half  as  many  cases  gives  almost  exactly  the  same 
proportion  for  the  two  races.  The  mortality,  however,  is 
stated  as  being  three  times  as  great  in  the  negro.  Tiffany's 
statistics  show  fifty-seven  per  cent,  of  abscess  for  the  white 
and  forty-three  per  cent,  for  the  black.  Kinloch  says,  "I 
think  suppuration  in  the  pure  black  is  less  than  in  the  white. " 
On  the  other  hand,  Richardson's  table,  from  a  much  smaller 
number  of  cases  shows  abscess  to  be  nearly  twice  as  common 
in  the  negro  as  in  the  white.  Corson  also  thinks  the  negro 
has  a  greater  susceptibility  to  pus  cocci.  My  statistics  would, 
however,  seem  to  bear  out  the  conclusion  of  Matas  that  "  Blacks 
are  not  more  subject  and  possibly  less  so  to  acute  circumscribed 
and  pyogenic  infections."  The  figures  in  my  table  for  furun- 
culosis alone  show  a  rather  striking  disproportion  with 
fifty-two  cases  in  the  white  and  only  fifteen  in  the  black. 

If  it  is  conceded  that  erysipelas,  contagious  impetigo,  and 
ecthyma  are  due  to  infection  by  the  streptococci,  it  would 
appear  from  my  figures  that  the  negro  shows  a  lessened  sus- 
ceptibility to  this  organism.  Of  these  combined  affections 
two  hundred  and  twenty-nine  were  present  in  whites  and 
one  hundred  and  eighty  in  blacks.  Richardson's  table  for 
erysipelas  shows  practically  the  same  proportion  in  the  two 
races,  while  the  figures  of  Matas  give  seventy  per  cent,  in  the 
white  and  forty-two  per  cent,  in  the  black  with  again  a  higher 
mortality  for  the  latter. 

A  study  of  the  more  important  inflammatory  diseases 
of  the  skin,  show,  I  think,  some  interesting  differences  in 
the  two  races.  I  have  been  greatly  surprised  to  find  in  my 
statistics,  the  comparatively  large  total  of  one  hundred 
and  one  cases  of  acne  in  the  black  as  opposed  to  one 
hundred  and  sixty-three  in  the  white.  If  mulattoes  could 


DERMATOLOGICAL  CONGRESS 


207 


have  been  excluded  from  my  table,  I  am  sure  a  much 
greater  disproportion  in  favor  of  the  blacks  would  have  re- 
sulted. I  have  for  some  time  scrutinized  every  negro  seen 
on  the  street,  as  well  as  in  the  clinic,  and  am  of  the  opinion 
that  in  New  York,  acne  of  the  face  is  decidedly  uncommon 
in  the  full-blooded  negro.  It  may  be  well  to  mention  that  the 
negro  population  of  our  city  is  somewhat  over  sixty  thousand, 
and  is  only  exceeded  by  that  of  Washington,  Baltimore,  New 
Orleans,  and  Philadelphia.  I  feel  very  certain  of  the  fact 
that  acne  in  the  negro  is  a  milder  affection  than  in  the  white, 
an  opinion  with  which  most  of  my  southern  colleagues  entirely 
agree,  Well  marked  cases  of  acne  indurata  in  the  dark 
race  are  indeed  rarities.  While  my  figures  for  acne  in  the 
blacks  show  four  and  six- tenths  per  cent,  of  the  total  cases 
of  skin  diseases,  Dyer's  show  only  one  and  nine-tenths  per 
cent,  and  Morison's  one  and  eight-tenths  per  cent.,  all  of  the 
latter's  cases,  nine  in  number,  being  mulattoes.  Only  six 
cases  of  acne,  of  which  four  occurred  in  whites,  are  given  in  the 
report  of  Rufz,  a  French  physician,  who  practised  medicine 
for  twenty  years  in  Martinique.  The  careful  observations 
of  Rufz  in  a  country  where  there  were  roughly  sixteen  times 
as  many  blacks  as  whites,  form  a  most  valuable  contribution 
to  the  dermatological  literature  of  the  negro. 

TABLE  II. 
SKIN  DISEASES  (2200  Whites  and  2200  Blacks.) 


WHITES 

BLACKS 

Cases 

Percentage 

Cases 

Percentage 

Acne  

163 

12 
IO 

I 

9 

2 

89 

5 
7 

22 

24 

3 
28 

.074 
.0054 
.0045 
.00045 
.0041 
.00091 
.0404 
.00227 
.00318 
.01 
.0109 
.00136 
.0127 

IOI 

i 

10 

3 
4 
8 

5° 
3 
3 
8 
6 

2 

16 

.046 
.00045 
.0045 
.00136 
.0018 
.00363 
.0227 
.00136 
.00136 
.00363 
.00272 
.00091 
.00727 

Alopecia  

Alopecia  Areata  

Callositas  

Chloasma  

Clavus  

Dermatitis  

Dermatitis  Herpetiformis  

Dermatitis  Medicamentosa  

Dermatitis  (Rhus)  

Dermatitis  Venenata  

Dysidrosis  

Ecthyma  

208 


SIXTH  INTERNATIONAL 


TABLE  II— Continued 
SKIN  DISEASES  (2200  Whites  and  2200  Blacks.) 


WHITES 

BLACKS 

Cases 

Percentage 

Cases 

Percentage 

49° 
28 

22 

4 

10 

4 

21 
2 
3 

5 

i 

52 
6 
7 
4 
197 

4 

i 
i 
4 

12 

5 
4 

12 

3 
54 
15 
5 

2 

7 
3 
ii 

49 

7 
25 

i 

243 
18 
16 
279 

5 
i7 

22 

16 

2 

7 
38 
6 
i 
5 
4 
28 

.222 

.0127 
.01 
.0018 
.0045 
.0018 
.0095 
.00091 
.00136 
.00227 
.00045 
.0236 
.00272 
.00318 
.0018 
.0895 
.0018 
.00045 
.00045 
.0018 
.0054 
.00227 
.0018 
.0054 
.00136 
.0245 
.00681 
.00227 
.00091 
.00318 
.00136 
.0050 
.0222 
.00318 
.0113 
.00045 
.  1104 
.00818 
.00727 
.1268 
.00227 
.00772 
.01 
.00727 
.00091 
.00318 
.0127 
.00272 
.00045 
.00227 
.0018 
.0127 

521 
28 

2 
10 
2 
0 
10 

3 
4 
9 
i4' 

15 
5 
3 

i 

154 
o 
10 

IO 

4 
8 
4 

2 
2 

7 
5 
20 

2 

4 
6 
8 

22 
IO 

I 
I 

4 
170 

23 
9 
595 
4 
56 

13 
18 

7 
9 
62 

17 
4 
8 
6 
3i 

.236 

.0127 
.00091 
.0045 
.00091 

.0045 
.00136 
.0018 
.0041 
.00636 
.00681 
.00227 
.00136 
.00045 
.070 

.0045 
.0045 
.0018 
.00363 
.0018 
.00091 
.00091 
.00318 
.00227 
.00909 
.00091 
.0018 
.00272 
.00363 
.010 
.0045 
.00045 
.00045 
.0018 
.0772 
.0104 
.0041 
.2070 
.0018 
.0254 
.00590 
.00818 
.00318 
.0041 
.0281 
.00772 
.0018 
.00363 
.00272 
.01409 

Eczema  Seborrhceicum       

Epitheliotna              

Erysipeloid                       

Erythema  and  E.  Hyperaemicum  .  . 
Erythema  Multiforme  

Favus                             

Folliculitis                       

Frost  Bite  and  Pernio  

Furunculosis                 

Ichthyosis  .            

Impetigo  Contagiosa               

Intertrigo              

Keloid              

Keratosis                 

Lichen  Planus                      

Lupus  Erythematosus       

Lupus  Vulgaris                     

Miliaria  and  Heat  Rash        

Paronychia  

Pediculosis  Capitis                 

Pediculosis  Corporis          

Pediculosis  Pubis                 

Pityriasis  Facei                   

Pityriasis  Rosea                 

Pruritus.  ...                          

Pruritus  Senilis  .           

Psoriasis  

Purpura  Simplex  

Rosacea  

Rubeola  

Scabies  

Seborrhcea  

Sycosis  

Syphilis  

Tinea  Barbae  

Tinea  Capitis  

Tinea  Circinata  

Tinea  Versicolor  

Ulcus  

TJlcus  Varicosus  

Urticaria  

Varicella  

Variola  

Verruca  

Vitiligo  

Zoster  

DERMATOLOGICAL  CONGRESS  209 

Two  cases  of  the  following  diseases  noted  in  whites — 
percentage  .00091 :  Adenoma  sebaceum,  carbuncle,  cyst 
(sebaceous),  erythema  nodosum,  erythema  scarlatiniforme, 
haemangioma,  naevus  unius  lateris,  papilloma. 

Two  cases  of  the  following  noted  in  blacks:  Angioneurotic 
oedema,  dysidrosis,  fibroma,  keratosis  pilaris,  molluscum 
contagiosum,  papilloma,  pityriasis,  prurigo,  scrofuloderma. 

One  case  of  the  following  noted  in  whites — percentage 
.00045:  Acne  frontalis,  acne  necrotica,  angioma  (infectious), 
balanitis,  callositas,  fibroma,  herpes  iris,  nsevus,  onychia, 
pemphigus,  prurigo,  pruritis  scroti,  pruritus  vulvas,  purpura 
(Henoch's),  purpura  haemorrhagica,  rotheln,  scarlatina,  se- 
borrhoeal  wart,  stomatitis,  urticaria  pigmentosa,  verruca 
necrogenica. 

One  case  of  the  following  noted  in  blacks :  Ainhum,  blasto- 
mycosis,  carbuncle,  dermatitis  calorica,  cornu  cutaneum, 
gangrene,  herpes  iris,  leukoplakia,  lichen  ruber,  lichen  scrofu- 
losorum,  morphcea,  mycosis  fungoides,  naevus,  oedema  (wood- 
en), Paget's  disease,  pemphigus,  pruritus  ani  et  vulvas, 
purpura  (Henoch's),  rotheln,  sarcoma,  stomatitis,  sudamina, 
thrush,  tuberculosis  of  nose. 

That  eczema  is  a  common  affection  in  the  negro  appears 
from  my  figures  of  four  hundred  and  ninety  cases  in  the  white 
and  five  hundred  and  twenty-one  in  the  black.  It  is  the  most 
common  disease  in  Martinique,  according  to  Rufz.  Twenty- 
three  per  cent,  of  the  total  number  of  blacks  in  my  table 
suffered  from  eczema.  Morison's  table  gives  nineteen  per 
cent,  and  Dyer's  fifteen  per  cent,  for  the  same  disease.  It 
is  probable  that  the  presence  of  mulattoes  influences,  to  some 
extent,  my  apparently  high  figures.  The  majority  of  my 
southern  colleagues  consider  eczema  to  be  less  frequent  in  the 
negro.  Practically  all  agree  that  it  is  less  severe.  Dr.  Car- 
michael  writes,  "It  is  equally  frequent,  but  less  severe." 
Morison  finds  acute  eczema  much  less  severe  in  negroes,  while 
the  chronic  form  appears  the  same  as  in  the  white,  except 
that  itching  is  less  acute.  In  answer  to  the  question,  "Have 
you  ever  seen  a  case  of  universal  eczema  in  the  negro?"  a 
few  of  my  correspondents  have  answered  in  the  affirmative. 

VOL.  I. — 14 


2IO 


Two  of  these  cases  occurred  in  patients  suffering  from 
diabetes. 

My  table  records  four  cases  designated  as  erythema  and 
erythema  hyperaemicum  in  whites  and  none  in  blacks.  Ery- 
thema multiforme  appears  twice  as  common  in  the  white, 
twenty-one  cases  being  recorded  for  the  former  against  two 
for  the  latter.  There  are  two  cases  of  erythema  nodosum  in  the 
white  and  three  in  the  black,  and  a  single  case  of  herpes  iris 
is  recorded  for  each  race. 

Lichen  planus,  which  from  my  experience  I  would  have 
concluded  to  be  fully  as  frequent  in  the  black  as  in  the  white, 
appears  two-thirds  as  frequent  in  my  figures,  which  show 
twelve  cases  in  the  white  and  eight  in  the  black.  A  single 
case  of  lichen  ruber  (the  pityriasis  rubra  pilaris  of  the  French) , 
is  recorded  as  occurring  in  a  negress,  no  case  having  been 
noted  in  the  whites.  An  illustration  showing  the  papular 
stage  of  this  rare  affection  appears  in  my  exhibition  of  photo- 
graphs.1 (Plate  ix,  Fig.  2.) 

A  comparative  analysis  of  psoriasis  in  the  two  races  brings 
to  light  some  facts  that  I  think  are  perhaps  not  generally 
known.  On  a  number  of  occasions  my  father  has  called  at- 
tention to  the  comparative  immunity  of  the  negro  to  psoriasis. 
At  a  recent  meeting  of  the  British  Medical  Association,  in 
discussing  a  paper  by  Dr.  Hyde,  he  further  expressed  the  view 
that  "possibly  the  savages  of  Africa  were  free  from  psoriasis 
on  account  of  exposure  of  the  skin  to  sunlight,  and  that  the 
negroes  of  North  America  inherited  this  peculiarity."  At 
the  same  meeting,  Dr.  Corlett  of  Cleveland,  stated  that  he 
had  "never  seen  psoriasis  in  the  negro,  although  he  had  seen 
many  skin  diseases  in  this  race."  My  figures  for  psoriasis 
show  forty-nine  cases  in  the  white  and  ten  in  the  black.  Mori- 
son  observed  twenty-six  cases  in  the  white  and  six  in  the 
black,  four  of  the  latter  cases,  however,  being  mulattoes. 
Dyer's  table  gives  two  cases  out  of  a  total  of  five  hundred 
and  fifty-six.  Stated  proportionally,  in  ten  thousand  cases 
my  figures  would  have  shown  two  hundred  and  twenty-two 
whites  and  forty-five  blacks.  Morison's  table  would  have 

»  A  photographic  exhibition  of  skin  diseases  in  the  negro.  Shown  at  the 
International  Congress  of  Dermatology. 


DERMATOLOGICAL  CONGRESS  211 

given  a  hundred  and  twenty  blacks  and  Dyer's  thirty-six. 
Great  as  is  this  disproportion  in  favor  of  the  blacks,  it  would 
certainly  have  been  very  much  greater  if  mulattoes  could  have 
been  eliminated  from  the  column  of  blacks.  In  his  entire 
experience  at  Martinique,  Rufz  stated  that  he  never  saw  a 
single  case  of  psoriasis  in  the  negro.  The  question  addressed 
to  my  correspondents,  "  Have  you  seen  many  genuine  cases 
of  psoriasis  in  full-blooded  negroes?"  should,  in  the  light  of  my 
present  knowledge,  have  read,  "Have  you  ever  seen  a  single 
case?"  With  two  exceptions,  all  have  answered  this  question 
in  the  negative,  many  volunteering  the  information  that  they 
had  seen  no  cases.  "Once  only,"  writes  Dr.  Grindon,  "in 
twenty-four  years  of  active  dermatological  practice  have  I 
seen  psoriasis  in  a  negro,  and  then  I  was  not  absolutely  certain 
of  my  diagnosis."  Dr.  Dyer  answers,  "I  have  seen  but  one 
case  of  psoriasis  in  the  negro  in  fifteen  years  of  practice."  Dr. 
Rosenthal  writes,  "Classifying  all  negro  descendants  as  ne- 
groes, I  have  six  cases  in  four  hundred  and  eighty.  None  of 
these  were  in  the  real  black  kinky-headed  African,  but  all  in 
mulattoes."  Dr.  Gilchrist  answers,  "A  few  cases,"  and  Dr. 
Brinkley  of  Savannah  says,  "  I  have  not  seen  a  single  case  or 
even  a  condition  suggesting  psoriasis."  In  marked  distinction 
to  these  answers  is  that  of  Dr.  Strobel  of  Baltimore,  who  states 
that  he  has  seen  "probably  twenty  cases."  I  have  been  un- 
able to  learn  what  proportion  of  Dr.  Strobel's  cases  were 
mulattoes.  In  Morison's  experience,  psoriasis,  when  it  does 
occur,  is  easily  cured  and  does  not  relapse. 

Twenty-five  cases  of  rosacea  in  the  white  to  one  in  the  black 
constitute  a  ratio  that  is  indeed  striking.  One  case  only  is 
recorded  in  Dyer's  tables,  while  Morison's  table  of  blacks  fails 
to  show  a  single  case.  While  the  beginning  stages  of  rosacea 
could  well  pass  unnoticed,  the  same  would  not  be  true  of  the 
latter,  especially  the  hypertrophic  stages.  Personal  obser- 
vation of  negroes  upon  the  street  and  in  the  clinic  leads  me  to 
the  conclusion  that  rosacea  in  the  dark  race  is  indeed  a  rare 
affection. 

Sycosis  was  seen  sixteen  times  in  the  whites  and  nine  times 
in  the  blacks.  One  case  was  recorded  in  Dyer's  and  one 
in  Morison's  table.  I  have  observed  the  tendency  to  the 


212  SIXTH  INTERNATIONAL 

formation  of  tiny  keloidal  tumors  in  several  cases  of  sycosis 
in  the  negro,  which  is  not  unusual  considering  the  great  ten- 
dency to  keloid  of  this  race. 

Urticaria  would  appear  to  be  the  only  inflammatory  disease 
of  the  skin  that  is  considerably  more  frequent  in  the  negro  than 
in  the  white,  my  figures  showing  thirty-eight  cases  in  the  white 
and  sixty-two  in  the  black.  Dyer's  table,  however,  shows 
the  small  number  of  two  cases,  while  Morison  records  eleven 
whites  and  seventeen  blacks.  From  my  experience,  I  would 
not  consider  urticaria  of  greater  frequency  in  the  negro.  I  feel 
sure  that  it  is  less  severe. 

Zoster  occurred  twenty-eight  times  among  the  whites  and 
thirty-one  times  among  the  blacks.  My  experience  agrees 
with  Morison's  statement,  that  this  affection  is  less  painful 
in  the  negro. 

A  study  of  tuberculosis  of  the  skin  tends  to  strengthen  my 
view  that  the  negro  is  less  susceptible  to  skin  diseases  than 
the  white.  From  innumerable  sources  it  can  be  shown  that 
pulmonary  tuberculosis,  and  to  a  less  extent  other  forms  of  the 
disease,  are  more  frequent  in  the  negro  than  in  the  white  race. 
In  view  of  these  facts  it  may  seem  strange  that  my  figures  for 
lupus  vulgaris,  a  typical  form  of  cutaneous  tuberculosis,  record 
four  cases  in  the  white  and  only  half  as  many  in  the  black.  A 
glance  at  my  column  for  negroes  shows,  however,  one  case 
designated  as  tuberculosis  of  the  nose,  two  cases  of  scrofulo- 
derma,  and  one  of  lichen  scrofulosorum.  Adding  thereto  the 
two  cases  of  lupus,  a  total  of  six  cases  of  tuberculous  affections 
in  the  negro  is  given.  This  is  partly  offset  by  one  case  of 
verruca  necrogenica  in  the  white  column,  which  brings  the 
white  total  to  five  cases  of  tuberculous  disease.  These  revised 
figures  of  six  blacks  and  five  whites  are  very  small  from  which 
to  draw  conclusions.  It  seems  to  me,  however,  that  in  view 
of  the  great  prevalence  of  tuberculosis  in  the  negro,  there  should 
have  been  considerably  more  cases  of  cutaneous  tuberculosis. 
That  there  were  not,  appears  further  proof  of  a  lessened  sus- 
ceptibility of  the  negro  to  diseases  of  the  skin. 

It  is  with  a  proper  realization  of  its  magnitude  that  I 
approach  the  subject  of  syphilis  in  the  negro.  It  may  be  well 
at  the  start  to  call  attention  to  certain  changed  conditions 


DERMATOLOGICAL  CONGRESS  213 

between  the  negro  of  slavery  times  and  the  negro  of  to-day. 
I  agree  with  certain  writers  who  claim  that  from  a  physical 
standpoint  the  negro  slaves  were  infinitely  better  off  than 
are  their  descendants  of  to-day.  Slaves,  being  valuable 
property,  were  treated  as  such  and  were  well  fed,  housed,  and 
clothed.  They  were  further  absolutely  kept  from  dissipation. 
When  freedom  came,  all  was  changed.  Close  crowding  in 
poorly  ventilated  houses,  poor  clothing  and  food,  and  failure 
to  observe  the  ordinary  laws  of  hygiene  are  the  causes  that 
have  changed  them,  as  McHattan  says,  from  the  most  healthy 
race  in  the  country  forty  years  ago,  to  the  most  diseased  one 
to-day.  An  utter  lack  of  morality  (Quillian  stating  that  in  a 
practice  of  sixteen  years  he  had  never  examined  a  negro  virgin 
over  fourteen) ,  a  strong  sexual  instinct,  and  lack  of  cleanliness 
seem  all  that  are  necessary  to  have  brought  about  a  wide- 
spread infection  with  syphilis. 

That  syphilis  in  the  negro  is  not  only  very  prevalent,  but 
more  so  than  in  the  white,  is  one  point  upon  which  the  majority 
of  writers,  my  correspondents,  and  statistics  agree.  My  table 
shows  two  hundred  and  seventy-nine  cases  of  syphilis  in  the 
white  and  five  hundred  and  ninety-six  cases  in  the  black,  or 
twelve  and  twenty-seven  per  cent,  respectively  of  the  totals 
for  each  race.  Morison  gives  sixteen  and  twenty- three  per 
cent,  respectively  for  both  races,  and  Dyer  twenty-six  per 
cent,  for  blacks.  Matas  shows  a  proportion  in  a  thousand 
cases  of  twenty-eight  whites  to  fifty-one  blacks.  I  have  com- 
piled a  second  table  from  the  Central  Dispensary  reports  for 
nine  years,  including  all  cases  of  syphilis  which  were  treated  in 
the  clinics  for  medicine,  surgery,  children,  gynecology,  throat 
and  chest,  skin,  genito-urinary,  and  nervous  diseases.  In  a 
total  of  fifteen  thousand  whites,  in  round  numbers,  there  were 
six  hundred  and  twenty-one  cases  of  syphilis,  while  in  a  total 
of  thirty-two  thousand  blacks,  there  were  roughly  nineteen 
hundred  cases  of  syphilis.  In  other  words,  while  there  were 
two  blacks  to  one  white  who  applied  for  treatment,  there 
were  three  blacks  to  one  white  suffering  from  syphilis. 
To  be  exact,  the  blacks  suffered  1.46  times  as  often  as  the 
whites.  From  all  these  figures  I  think  it  can  safely  be 
inferred  that  syphilis,  if,  not  almost  universal  as  Murrell 


2i4  SIXTH  INTERNATIONAL 

claims,  is  at  least  more  prevalent  in  the  negro  than  in  the 
white  race. 

The  question  of  the  relative  severity  of  syphilis  in  the  two 
races  is  a  much  more  difficult  one  than  that  of  relative  fre- 
quency. That  acquired  syphilis  is  not  more  virulent  in  the 
negro,  but  possibly  less  so,  I  am  inclined  to  think  from  the 
following  reasons.  First — that  the  primary  and  secondary 
manifestations  do  not  appear  to  be  more  severe.  Second — 
that  tertiary  manifestations  do  not  seem  to  be  more  common. 
Third — that  in  the  negro  the  disease  seems  more  amenable 
to  treatment. 

It  may  be  stated,  as  a  general  rule,  that  negroes  do  not 
realize  the  importance  of  syphilis  and  are  rarely  willing  to 
continue  treatment  after  visible  manifestations  have  disap- 
peared. When  they  do  submit  to  treatment,  the  disease 
responds  more  readily,  I  think,  than  in  the  white  race.  In 
speaking  of  syphilis,  Byers  writes,  "It  is  more  amenable  to 
treatment  than  in  the  white  race."  According  to  Powell,  "  The 
disease  is  far  more  amenable  to  treatment  in  the  negro  than 
in  the  white,  the  cases  yield  readily,  and  the  cures  are  more 
permanent  and  satisfactory."  "Twenty-eight  years  of  ex- 
perience in  the  practice  of  medicine  in  the  South,"  writes 
Dixon,  "have  convinced  me  that  the  only  difference  in  the 
two  races  is  that  the  disease  yields  more  kindly  to  treatment 
in  the  negro  race." 

A  greater  tendency  to  pustulation  in  secondary  syphilis  of 
the  negro  might  be  considered  proof  of  its  greater  virulence 
in  this  race.  Atkinson,  in  speaking  of  his  cases  of  pustular 
syphilis  in  a  paper  on  early  syphilis  in  the  negro,  says  the 
"course  of  the  pustular  eruptions  was  uniformly  benign," 
and  further,  "the  presence  of  pustulation  was  no  evidence 
of  special  severity  of  the  disease  and  generally  no  unusual 
refractoriness  to  treatment  was  encountered." 

In  an  attempt  to  see  whether  some  of  the  severe  tertiary 
lesions  of  syphilis  were  more  frequent  in  the  negro  than  in  the 
white,  I  have  tabulated  cases  from  the  surgical  clinic  of  the 
Central  Dispensary  designated  as  syphilitic  ulcer  (most  of 
them  situated  upon  the  leg).  It  has  given  for  this  form  of 
tertiary  syphilis  a  proportion  of  one  hundred  and  fifty- four 


DERMATOLOGICAL  CONGRESS 


215 


cases  in  the  black  to  one  hundred  in  the  white.  A  similar 
table  from  the  throat  clinic,  comprising  cases  of  syphilitic 
ulceration  of  the  larynx,  pharynx,  palate,  and  nasal  bones 
(the  majority  presumably  tertiary),  gave  a  proportion  of  only 
one  hundred  and  thirty-one  blacks  to  one  hundred  whites. 
Figures  from  the  clinic  for  nervous  diseases  show  a  proportion 
of  three  hundred  and  sixty-six  cases  of  cerebral  syphilis  in  the 
black  to  one  hundred  in  the  white,  and  on  the  other  hand 
only  one  hundred  and  four  cases  of  locomotor  ataxia  in  the 
black  to  one  hundred  in  the  white.  Hecht  has  called  atten- 
tion to  the  fact  that,  although  syphilis  is  extremely  preva- 
lent in  the  negro,  locomotor  ataxia  is  rare  in  this  race. 
As  my  table  of  eight  clinics  showed  the  proportional  fre- 
quency for  all  cases  of  syphilis  to  be  one  hundred  and 
forty-six  blacks  to  one  hundred  whites,  it  is  seen  that,  with  the 
exception  of  the  cerebral  syphilis,  the  tertiary  lesions 

TABLE  III 
SYPHILIS 


WHITES 

NEGROES 

Disease 

Clinic 

Total 
Patients 

Cases 

Percent- 

Total 
Patients 

Cases 

Percent- 

Applying 

age 

Applying 

age 

Grand    total 

Eight 

of  all  cases 

differ- 

of syphilis 

ent 

clinics 

15.672 

621 

.0396 

32537 

1895 

.0582 

Syphilitic  ul- 

cer, leg 

Surgical 

4,072 

70 

.0171 

6873 

182 

.0264 

Syphi  lit  ic 

ulceration 

of  pharynx, 

larynx,  pal- 

ate ,  and  na- 

sal bones 

Throat 

2,152 

82 

.038 

4700 

235 

•°5 

Cerebral 

syphilis 

Nervous 

990 

15 

.015 

739 

41 

•055 

Locomotor 

ataxia 
Congenital 

Nervous 

990 

9 

.0090 

739 

7 

.0094 

syphilis 

Children 

2,954 

23 

.0077 

4631 

81 

.0181 

Statistics  from    Central    Dispensary,   1898  to    1906.    (Congenital   syphi- 
lis, 1897  to  1906.) 


216  SIXTH  INTERNATIONAL 

mentioned  above  did  not  show  any  unusual  frequency  in  the 
negro.  The  writer  is  fully  aware  that  the  figures  are  smaller 
and  only  deal  with  a  few  phases  of  such  a  varied  disease  as 
tertiary  syphilis.  They  cannot  do  more  than  convey  a  sug- 
gestion as  to  the  virulence  of  this  disease. 

In  expressing  an  opinion  upon  the  severity  of  syphilis  in 
the  negro,  I  have  had  in  mind  only  the  acquired  form  of  the 
disease.  That  the  hereditary  form  is  more  virulent  and  is  an 
important  factor  in  raising  the  negro  mortality,  I  think  prob- 
able. According  to  Hoffmann,  the  mortality  from  premature 
and  still  births,  is  greater  in  the  negro  than  in  the  white. 
Corson  writes:  "I  believe  the  direct  mortality  from  syphilis 
in  the  negro  is  chiefly  to  be  found  in  the  ante-natal  mortality 
and  in  that  of  early  babyhood."  A  table  compiled  from  the 
children's  department  of  the  Central  Dispensary  shows,  in  an 
equal  number  of  patients,  two  and  a  third  times  as  many 
hereditary  syphilitic  children  in  the  blacks  as  in  the  whites. 

In  answer  to  the  question  "  Is  syphilis  more  virulent  in  the 
negro?"  the  majority  of  my  correspondents  have  answered  in 
the  negative,  and  some  have  added,  "less  virulent."  Certain 
others,  however,  whose  opinions  carry  great  weight,  consider 
syphilis  in  the  negro  to  be  more  virulent. 

Surgeon  Carter,  in  a  comparative  study  of  two  hundred  and 
thirty-one  cases  of  syphilis  in  the  two  races,  concludes  that  the 
disease  pursues  a  milder  course  in  the  negro  than  in  the  white. 
In  speaking  of  the  negro,  Kinloch  says,  "  I  do  not  think  he  is 
affected  to  the  same  extent  (as  the  white)  by  syphilitic  poison." 
Quillian  writes,  "  One  thing  is  certain,  the  lesions  are  not  as 
severe  in  the  black  as  in  the  white  race."  Although  the  figures 
of  Matas  give  a  mortality  three  times  as  great  for  the  blacks  as 
for  the  whites,  he  concludes  that  "if  the  mulattoes  could  be 
eliminated  from  the  calculation  the  results  would  prove,  other 
conditions  being  equal,  syphilis  to  be  less  virulent  and  less 
fatal  in  the  pure  negro  than  in  the  white. 

In  considering  some  of  the  peculiarities  of  syphilis  in  the 
negro,  attention  is  first  called  to  those  of  the  initial  lesion. 
According  to  Morison,  the  chancre  is  attended  by  a  greater 
amount  of  induration.  Lofton  states  that  it  has  been  his 
experience  to  "observe  as  a  rule  double  chancre  (especially 


DERMATOLOGICAL  CONGRESS  217 

when  located  upon  the  genitalia  or  its  covering)  in  the  negro 
subject."  Multiple  chancre  occurred  in  seventeen  out  of 
forty-five  cases  reported  by  Atkinson.  The  latter  writer  lays 
stress  upon  the  modification  of  syphilis  in  the  negro  due  to  the 
great  prevalence  of  scrofula.  This  is  seen,  for  instance,  in 
the  marked  inflammatory  action  of  the  glands  in  relation  to 
chancre. 

That  general  enlargement  of  the  lymphatic  glands  is  more 
constant  and  more  marked  in  the  negro,  no  one,  I  think,  will 
dispute.  In  Dr.  Carter's  table,  enlarged  glands  were  noted 
in  fifty-nine  whites  and  in  one  hundred  and  two  blacks.  Tif- 
fany states,  "  Enlargements  of  lymphatic  glands  are  apt  to  be 
marked  in  the  syphilitic  negro  compared  with  the  white  race." 
That  the  pustular  syphilide  in  the  negro  is  somewhat  more 
common  than  in  the  white  seems  probable.  According  to 
Tiffany,  "  excessive  pus  formation  occurs  in  the  negro  not 
only  with  scrofulous  affections  but  with  syphilitic  as  well." 
Carter  states  that  in  the  negro  syphilis  is  marked  by  few 
cutaneous  lesions,  and  these  mainly  pustular.  A  peculiar 
appearance  has  been  observed  by  Taylor  in  two  cases  of 
papular  syphilis  in  the  negro.  The  eruption  consisted  of 
large  flat  papules,  "nearly  of  a  snow-white  in  spots  where  the 
skin  was  kept  clean,  and  of  a  dirty- white  elsewhere."  Refer- 
ence to  lesions  of  the  mucous  membrane  and  to  the  occurrence 
of  pruritus  in  syphilis  will  be  made  later. 

If  I  were  asked  what  I  considered  from  my  experience  to 
be  the  most  striking  dermatological  peculiarity  of  the  negro, 
I  would  say  without  hesitation,  the  annular  syphilide.  (See 
Plate  x,  Figs.  3,  4,  5  and  6.)  This  form  of  syphilis,  it  seems  to 
me,  should  be  classed  with  keloid  and  elephantiasis  as  affec- 
tions that  are  very  common  and  distinctive  in  the  negro.  Com- 
paratively little  has  been  written  about  the  annular  syphilide, 
and  still  less  on  its  relation  to  the  negro.  The  subject  has 
been  ably  discussed  by  Atkinson  in  a  paper  entitled  ' '  Syphilo- 
derma  Papulosum  Circinatum. "  This  title  well  describes  the 
condition  to  which  I  have  reference,  the  lesions  being  sim- 
ply flat  papules  that  have  cleared  up  in  the  centre  and  then 
left  elevated  rims  to  form  various-sized  circles.  The  erup- 
tion, as  you  well  know,  is  one  of  the  early  period  of  syphilis, 


2i8  SIXTH  INTERNATIONAL 

and  is  to  be  sharply  differentiated  from  the  circinate  grouping 
of  tubercles  of  late  syphilis.  I  have  seen  the  annular  syphilide 
most  often  about  the  nose  and  mouth,  though  it  may  also 
occur  on  the  trunk  and  upper  extremities.  Though  I  have 
seen  the  eruption  only  in  the  form  of  partial  or  complete 
circles  or  festoons,  it  may  assume  extremely  fantastic  designs 
resembling  scrollwork,  an  example  of  which  is  shown  in  the 
extraordinary  photograph  kindly  given  me  by  Dr.  Carmichael. 
A  somewhat  similar  though  less  well-marked  illustration  is 
shown  by  Jullien  in  his  Maladies  Veneriennes.  Fine  illustra- 
tions of  the  annular  syphilide  are  to  be  seen  in  the  atlases  of 
Wilson,  Taylor,  Morrow,  and  Pringle,  but  no  reference  is  made 
to  the  disease  in  the  negro.  Photographs  of  the  annular 
syphilide  in  the  negro  appear  in  the  text-books  of  Stelwagon 
and  Pusey,  and  both  of  these  writers  state  that  the  disease  is 
more  common  in  the  black  than  in  the  white.  In  my  sta- 
tistics obtained  from  the  Johns  Hopkins  Dispensary,  out  of  a 
thousand  consecutive  cases  of  skin  disease  in  the  white  there 
were  seventy -two  cases  of  syphilis,  none  of  them  presenting  the 
annular  form  of  the  disease .  In  the  corresponding  one  thousand 
cases  in  the  negro,  there  were  one  hundred  and  ninety- three 
cases  of  syphilis,  eleven  of  which,  or  .057  per  cent.,  presented 
examples  of  the  annular  syphiloderm.  Finally,  it  may  be 
remarked  that  the  diagnosis  is  uniformly  easy,  though  to  one 
unfamiliar  with  these  lesions  the  eruption  might  readily 
be  mistaken  for  the  annular  form  of  erythema  multiforme 
or  for  ringworm. 

Of  the  benign  tumors  of  dermatological  interest,  I  should 
like  to  call  your  attention  to  one  that  is  characteristic  of  the 
negro,  namely,  keloid.  In  an  effort  to  obtain  as  large  figures 
as  possible  upon  this  subject,  I  have  tabulated  the  cases  from 
the  surgical  and  from  the  ear  departments  of  the  Central 
Dispensary.  These  figures,  added  to  those  of  my  general 
table,  give  a  total  of  three  cases  of  keloid  in  the  white,  and 
the  rather  surprising  number  of  seventy-six  cases  in  the  black. 
In  proportion  to  the  total  patients  of  each  race  treated  in 
these  clinics,  keloid  was  eighteen  and  seven-tenths  times 
more  frequent  in  the  negro  than  in  the  white.  The  figures  of 
Matas  from  a  small  number  of  cases  show  keloid  to  be  nine 


DERMATOLOGICAL  CONGRESS 


219 


times  as  frequent  in  the  negro.     Morison's  table  gives  three 
cases  in  the  pure  black  and  none  in  the  mulattoes  or  whites. 


TABLE  IV 
TUMORS 


Disease 

Clinic 

WHITES 

NEGROES 

Total 
Patients 
Applying 

Cases 

Percent- 
age 

Total 
Patients 
Applying 

Cases 

Percent- 
age 

Angioma  
Carcinoma..  .  . 
Epithelioma  .  . 
Fibroma  

Surgi- 
cal and 
skin 
Surgi- 
cal and 
skin 
Surgi- 
cal and 
skin 
Surgi- 
cal and 
skin 
Ear,  Surg. 
and 
skin 
Surgi- 
cal and 
skin 
Surgi- 
cal and 
skin 
Surgi- 
cal and 
skin 

6,272 
6,272 
6,272 
6,272 
8,382 
6,272 
6,272 
6,272 

i 

13 
46 

7 
3 

5 

22 

7 

.000159 
.00207 

•00733 
.001  1  1 
.00035 
.00079 
.00350 

.OOIII 

9.073 

9,073 
9,073 
9,073 
11,486 

9,073 

9,073 
9,073 

3 
16 

5 
14 
76 

39 
27 

12 

.00033 
.00176 
.00055 
.00154 
.0067 
.00429 
.00298 
.00132 

Keloid  

Liporna  

Papilloma.  .  .  . 
Sarcoma  

Statistics  from  Surgical  Clinic  of  Central  Dispensary,  1898  to  19061 
plus  figures  given  in  Table  II.  Statistics  for  keloid  contain  in  addition 
cases  from  Ear  Clinic,  1898  to  1906. 

Dyer  states  that  in  two  thousand  five  hundred  and  thirty- 
eight  cases  of  skin  disease,  twenty-one  per  cent,  of  which 
were  negroes,  he  observed  five  cases  of  keloid  in  whites  and 
only  three  in  blacks.  The  small  number  of  cases  in  the  negro 
was  explained  by  Dr.  Dyer  from  the  fact  that  the  negro  rarely 
seeks  medical  assistance  unless  compelled  to  do  so  by  un- 
bearable conditions.  Balloch  calls  attention  to  the  fact 
that  in  the  statistics  of  the  American  Dermatological  Asso- 
ciation for  keloid,  although  no  mention  is  made  of  color,  the 


22o  SIXTH  INTERNATIONAL 

majority  of  cases  are  reported  from  cities  having  a  large 
negro  population.  The  same  writer  saw  nine  cases  of  keloid 
in  one  hundred  and  fifty-two  blacks  and  no  cases  in  three 
hundred  and  ninety-two  whites.  The  statistics  of  James  C. 
White  give  fifteen  cases  of  keloid  in  ten  thousand  American 
dispensary  cases,  among  which  were  doubtless  many  negroes. 
There  were  five  cases  of  keloid  in  ten  thousand  Scotch  pa- 
tients, and  none  in  three  thousand  Irish  patients,  all  of  which 
were  presumably  white.  In  twenty-three  thousand  nine 
hundred  and  forty-four  cases  from  the  Vienna  Clinic,  one 
case  only  of  keloid  was  reported.  That  the  lobule  of  the  ear 
is  a  very  favorite  site  for  keloid  is  seen  from  my  figures,  which 
record  for  this  situation  twenty-four  cases,  eighteen  of  which 
were  females.  Scheppegrell,  in  eleven  thousand  eight  hun- 
dred and  fifty-five  cases  of  diseases  of  the  nose,  throat,  and 
ear,  found  eight  cases  of  keloid  of  the  lobule,  seven  of  which 
were  negroes,  one  a  mulattress  and  one  a  white  person. 

From  all  of  these  figures  it  can  readily  be  seen  why  keloid 
is  so  often  classed  as  one  of  the  three  common  and  distinctive 
diseases  of  the  negro,  the  others,  as  you  know,  being  elephan- 
tiasis and  uterine  fibroid.  According  to  Balloch,  fibroid 
processes  as  represented  by  these  three  affections  are  so  much 
more  common  in  the  negro  that  they  constitute  a  racial 
peculiarity. 

In  connection  with  keloid  I  should  like  to  remind  you  of 
the  frequency  in  the  negro  of  an  allied  affection,  the  so-called 
keloid  acne  or  dermatitis  papillaris  capillitii  of  Kaposi.  That 
this  disease  is  very  common  in  the  negro  as  compared  with 
the  white,  is  seen  from  my  figures  giving  ten  cases  for  the 
former  and  only  one  for  the  latter.  A  number  of  illustrations 
of  this  peculiar  condition  are  to  be  seen  in  my  exhibition  of 
photographs.  (Fig.  i,  Plate  ix,  Figs.  7  and  10,  Plate  xi.) 

A  glance  at  my  table  of  tumors,  which  is  unfortunately 
of  very  meagre  proportions,  shows  papilloma  to  be  about 
equally  frequent  in  the  two  races.  Angioma  is  twice  as 
frequent,  and  lipoma  nearly  five  and  one-half  times  as  fre- 
quent in  the  negro  as  in  the  white.  Of  the  malignant  growths, 
sarcoma  is  slightly  more  common  and  carcinoma  slightly  less 
common  in  the  negro  than  in  the  white. 


DERMATOLOGICAL  CONGRESS  221 

It  is  not  my  intention  in  this  paper  to  discuss  the  general 
subject  of  cancer  in  the  negro.  I  wish  merely  to  call  atten- 
tion to  that  form  of  malignant  growth  of  such  importance 
to  the  dermatologist,  namely,  cutaneous  epithelioma.  In  this 
affection  we  appear  to  have  another  example  of  the  lessened 
susceptibility  to  skin  diseases  that  is  enjoyed  by  the  negro. 
Epithelioma  in  my  table  appears  thirteen  and  three-tenths 
times  as  often  in  the  white  as  in  the  black.  In  Tiffany's 
statistics  there  is  not  a  single  case  of  epithelioma  of  the  face 
or  lip  of  a  negro.  Yandell  stated  that  he  had  never  seen  an 
epithelioma  on  the  face  of  a  negro.  Christopher  Johnston 
said  that  he  had  only  infrequently  met  with  epithelioma  in  the 
negro  race,  and  nearly  all  with  whom  I  have  corresponded 
have  had  a  similar  experience. 

Some  very  interesting  figures  and  conclusions  are  given 
by  Hyde  upon  this  subject  in  a  recent  contribution  on  the 
"  Influence  of  Light  in  the  Production  of  Cancer  of  the  Skin." 
The  figures  which  relate  to  deaths  from  cancer  of  the  head, 
neck,  and  face  (practically  that  of  the  skin)  are  taken  from 
the  last  census  reports  of  two  Southern  States  of  about  equal 
population.  The  returns  lack  only  ten  of  reporting  twice 
as  many  fatal  cases  of  cancer  in  the  Northern  as  in  the  Southern 
States.  This  appears  significant  when  it  is  considered  that 
half  the  population  of  the  southern  states  consisted  of  negroes. 
The  writer  concludes  that  the  physiological  pigmentation  of 
the  skin  in  the  colored  race  seems  to  furnish  immunity  against 
cancerosis  of  that  organ.  Finally,  although  firmly  convinced 
that  epithelioma  in  the  full-blooded  negro  is  decidedly  un- 
common, I  must  in  fairness  mention  the  fact  that  the  sta- 
tistics of  Richardson  actually  show  a  greater  frequency  of 
epithelioma  in  blacks  than  in  whites. 

I  have  long  been  under  the  impression  that  itching  was  a 
more  or  less  characteristic  feature  of  skin  affections  in  the 
negro.  This  would  appear  to  be  borne  out  by  my  statistics 
giving  about  twice  as  many  cases  of  pruritus  of  different 
forms  in  the  blacks  as  in  the  whites ;  while  the  figures  of  Mori- 
son  record  twenty-four  cases  of  pruritus  in  pure  blacks  and 
five  in  whites.  Since  my  attention  has  been  specially  directed 
to  this  subject,  I  have  concluded  that,  while  negroes  may 


222  SIXTH  INTERNATIONAL 

complain  of  itching  more  often  than  whites,  the  visible  results 
of  scratching  are  certainly  much  more  marked  in  the  latter 
race.  It  is  probable  that  the  papular  syphilide,  though 
giving  rise  at  times  to  pruritus  in  the  white,  is  more  likely 
to  do  so  in  the  negro  race. 

Of  the  pigmentary  diseases  vitiligo  appears  in  my  table 
more  frequent  among  the  blacks,  the  proportion  being  six  blacks 
to  four  whites.  (Plate  xii,  Figs,  n  and  12.)  Morison's  figures 
show  four  cases  in  the  black  to  one  in  the  white.  On  the  other 
hand,  chloasma  appears  in  my  table  to  be  twice  as  common 
in  the  white  as  in  the  black.  That  these  figures  do  not  repre- 
sent the  actual  conditions,  I  feel  perfectly  confident.  It  is 
natural  that  a  negro  with  such  a  striking  affection  as  vitiligo 
would  be  more  apt  to  seek  medical  aid  than  a  white  person 
with  the  same  disease,  whereas  the  conditions  would  be 
exactly  reversed  in  the  case  of  chloasma.  Atkinson  con- 
sidered that  vitiligo  was  only  apparently  more  common  in  the 
negro,  not  actually  so.  Chloasma  in  the  pure  black  would 
often  pass  unnoticed.  In  the  mulatto,  however,  it  is  no- 
ticeable and  of  more  frequent  occurrence  than  in  the  whites, 
in  my  opinion.  Rufz  stated  that  chloasma  was  remarkable 
for  its  frequency  and  extent  in  mulatto  women.  Atkinson 
also  considered  chloasma  to  be  especially  common  in  those 
of  mixed  descent.  Whether  pigmentation  following  in- 
flammatory and  other  lesions  is  more  common  in  the  pure 
black  than  in  the  white,  it  is  difficult  to  judge  for  obvious 
reasons.  That  it  is  more  common  in  the  mulatto  than  in 
the  white,  I  feel  convinced. 

A  comparison  of  the  parasitic  diseases  in  my  table 
shows  two  hundred  and  forty-three  cases  of  scabies  in  the 
white  and  one  hundred  and  seventy  in  the  black.  There 
were  fifteen  cases  of  pediculosis  corporis  in  the  white  and 
twenty  in  the  negro,  a  rather  small  number  for  the  latter,  con- 
sidering his  uncleanly  habits.  The  figures  for  pediculosis  capitis 
show  a  rather  striking  disproportion,  namely,  fifty-four  cases 
in  the  white  and  only  five  in  the  black.  This  might  indicate 
that  the  negro  scalp  is  less  irritated  by  the  presence  of  pediculi 
and  that  he  in  consequence  does  not  seek  the  clinic  as  often 
as  the  white.  It  may,  however,  indicate  that  the  negro  takes 


DERMATOLOGICAL  CONGRESS  223 

greater  pains  in  the  care  of  the  scalp  than  the  lower  class  of 
whites  that  attend  our  clinics.  Dr.  Carmichael  informs  me 
that  the  negro  women  in  Virginia  take  a  special  pride  in  keep- 
ing their  heads  and  those  of  their  children  free  from  lice. 
Dr.  Pendergrast,  of  Memphis,  suggests  that  negro  women  un- 
consciously and  of  necessity  employ  one  of  the  methods  of 
treating  pediculosis,  namely,  the  fine  tooth  comb.  In  con- 
trast to  the  figures  for  pediculosis  are  those  of  tinea  capitis, 
which  show  seventeen  cases  in  the  white  and  fifty-six  in  the 
black.  A  similar  proportion  is  given  in  Morison's  statistics 
with  fourteen  whites  and  forty-two  blacks.  Both  favus  and 
chromophytosis  appear  in  my  table  slightly  more  common  in 
the  negro  than  in  the  white. 

My  figures  for  seborrhoea  show  eighteen  cases  in  the  white 
and  twenty-three  in  the  black.  On  the  other  hand  there  are 
twelve  cases  of  alopecia  in  the  white  and  only  one  in  the  black, 
representing  in  my  opinion  the  relative  proportion  of  baldness 
in  the  two  races.  Alopecia  areata  appears  ten  times  in  both 
races,  a  rather  high  proportion  for  the  blacks,  it  appears  to  me. 
It  is  well  known  that  canities  makes  its  appearance  considerably 
later  in  the  negro  than  in  the  white,  marked  grayness  being 
a  sure  sign  of  advanced  age  in  the  former  race. 

It  may  not  be  out  of  place  in  this  paper  to  show  some 
evidence  that  the  mucous  membrane  of  the  negro  shares  with 
the  skin  a  lessened  susceptibility  to  disease.  According  to 
T.  E.  Murrell,  "In  the  adult  negro  nasal  and  pharyngeal  dis- 
eases are  quite  infrequent."  Scheppegrell  states,  "In  the 
diseases  of  the  nose  we  find  a  proportionately  small  number 
of  negroes  affected."  The  same  writer  gives  some  figures 
showing  the  proportion  of  diseases  of  the  mouth  and  tongue 
to  be  forty-two  blacks  to  one  hundred  whites.  Carter  states 
that  the  mucous  membranes  of  the  negroes  are  less  vulnerable 
to  syphilis  than  those  of  the  white.  In  his  table  of  syphilitic 
lesions  of  the  mouth  and  fauces  there  were  thirty-nine  cases 
of  hypersemia  of  the  fauces  in  the  white  and  only  six  in 
the  negro,  though  the  writer  admits  that  this  condition  is 
probably  more  common  than  is  here  indicated.  There  were, 
however,  thirty-one  cases  of  mucous  patch  in  the  white  and 
none  in  the  black,  a  disproportion  that  is  indeed  striking. 


224  SIXTH  INTERNATIONAL 

My  attention  has  lately  been  called  to  the  rarity  of  leuko- 
plakia  in  the  negro,  while  studying  a  case  of  leukoplakia 
buccalis  which  I  have  been  fortunate  enough  to  have  under  my 
charge.  (See  Figs.  8  and  9,  Plate  xi.)  I  have  again  called  upon 
my  correspondents  for  aid  and  addressed  the  question,  "Have 
you  seen  many  cases  of  leukoplakia  in  the  negro?"  As  in  the 
case  of  psoriasis,  the  question  should  have  read,  "  Have  you 
ever  seen  a  single  case?"  Most  of  my  colleagues  answered 
simply  "No."  Four  stated  that  they  had  seen  several  cases. 
Dr.  Carmichael  had  seen  "one  case  in  a  full-blooded  negro," 
while  such  good  observers  as  Drs.  Dyer,  Engman,  Grindon, 
and  Mastin  stated  that  they  had  never  seen  a  case  of  leuko- 
plakia in  the  negro.  I  have  been  unable  to  find  any  reference 
in  text-books  on  dermatology  or  syphilis  to  this  peculiar 
immunity  enjoyed  by  the  negro. 

That  the  negro  may  suffer  as  well  as  the  white  man  from 
some  of  the  rarer  diseases  of  the  skin,  is  seen  from  my  list  of 
affections  in  which  one  case  of  each  disease  was  recorded. 
Included  in  this  list  are  blastomycosis,  herpes  iris,  lichen 
ruber,  lichen  scrofulosorum,  morphcea,  mycosis  fungoides, 
Paget's  disease,  pemphigus,  and  Henoch's  purpura.  The  case 
of  blastomycosis  was  one  of  the  two  negroes  that  have  been 
reported  by  Dr.  Gilchrist.  The  only  case  of  blastomycosis 
which  it  has  been  my  fortune  to  treat  is  that  of  a  mulatto 
with  a  lesion  upon  the  buttock,  an  illustration  of  which  also 
appears  in  my  collection.  One  case  of  ainhum  is  recorded 
in  my  statistics  which,  like  nearly  all  of  the  cases  of  this 
peculiar  disease,  was  noted  in  a  negro.  My  figures,  strange 
to  say,  do  not  include  a  single  case  of  elephantiasis. 

A  consideration  of  the  exanthemata  opens  up  such  a  large 
field  for  discussion  that  I  have  felt  it  advisable  to  omit  any 
reference  to  this  subject,  and  devote  my  time  to  those  more 
strictly  dermatological. 

Finally,  I  should  like  to  express  a  single  opinion  upon  the 
relative  susceptibility  of  the  negro  and  the  mulatto  to  skin 
diseases.  I  feel  convinced  that  in  general  the  mulatto  is  more 
susceptible  to  diseases  of  the  skin  than  the  full-blooded  negro, 
this  being  especially  true  of  acute  inflammatory  diseases, 
chloasma,  and  cutaneous  tuberculosis. 


DERMATOLOGICAL  CONGRESS  225 

CONCLUSIONS 

i — In  spite  of  the  fact  that  the  negro  is  more  susceptible 
to  disease  in  general  than  the  white  man,  and  that  his  mor- 
tality is  twice  as  great,  he  suffers  less  frequently  and  less 
severely  from  diseases  of  the  skin. 

2 — The  negro  skin  is  decidedly  less  susceptible  to  external 
irritants. 

3 — The  full-blooded  negro  is  almost  immune  to  ivy 
poisoning. 

4 — Acne  is  less  common  and  much  less  severe  in  the 
negro.  Rosacea  is  a  rare  and  very  mild  affection.  Eczema 
is  perhaps  not  less  frequent  though  certainly  less  severe. 
Psoriasis  in  the  full-blooded  negro  is  very  uncommon. 

5 — Tuberculosis  of  the  skin  is  not  more  common  in  the 
negro  in  spite  of  the  great  prevalence  in  this  race  of  pulmonary 
and  other  forms  of  tuberculosis. 

6 — Syphilis  is  certainly  more  common  in  the  negro  than 
in  the  white.  It  is  probably  not  more  virulent.  Tertiary 
forms  are  not  more  common.  A  tendency  to  the  annular 
syphilide,  as  well  as  to  keloid,  elephantiasis,  and  fibroma, 
deserves  to  be  classed  as  a  racial  peculiarity  of  the 
negro. 

7 — The  negro  is  more  subject  to  new  growths  of  connective 
tissue  origin  and  less  so  to  those  originating  in  epithelial 
structures.  Cutaneous  epithelioma  is  very  rare  in  the  full- 
blooded  negro. 

8 — The  mucous  membranes  as  well  as  the  skin  are  less 
susceptible  to  disease.  Leukoplakia  is  seen  in  the  negro  with 
extreme  rarity. 

9 — Many  of  the  rarer  forms  of  skin  disease  are  observed  in 
the  negro  as  well  as  in  the  white  race. 

10 — Mulattoes  are  more  susceptible  to  skin  diseases  than 
negroes,  being  especially  prone  to  chloasma. 

In  closing,  I  desire  to  express  my  thanks  to  Drs.  Gilchrist 
and  Carmichael  for  their  kindness  in  putting  the  statistics 
of  their  clinics  at  my  disposal.  I  am  also  indebted  to  Dr. 
Grindon  for  a  long  letter  containing  many  valuable  suggestions. 
Finally,  I  must  express  my  deep  gratitude  for  the  assistance 

VOL.    I. — 1$ 


226  SIXTH  INTERNATIONAL 

so  kindly  rendered  by  my  numerous  correspondents  scattered 
throughout  the  South. 

DESCRIPTION  OF  PLATES 

PLATE    ix. — FIG.  i.     Keloid.     Case  of  Dr.  R.  J.  Devlin  of  New  York. 

FIG.  2.     Lichen  ruber  acuminatus. 

PLATE  x. — FIGS.  3  and  4.  Hereditary  syphilis,  showing  the  annular 
form.  The  mother  of  this  child  had  also  manifested  syphi- 
litic lesions. 

FIGS.  5  and  6.     Acquired  syphilis,  showing  the  annular  form. 
Case  of   Dr.    R.   B.   Carmichael  of   Washington.     Eruption 
appeared  about  six  months  after  initial  lesion. 
PLATE    xi. — FIG.  7.     Keloid  acne. 

FIGS.  8  and  9.     Leukoplakia  buccalis. 
FIG.  10.     Multiple  keloid. 
PLATE  xii. — FIG.  u.     Leukonychia. 
FIG.  12.     Vitiligo. 

REFERENCES 

ATKINSON,  I.  E.  "Early  Syphilis  in  the  Negro."  Maryland  Medical 
Journal,  1877,  p.  135. 

ATKINSON,  I.  E.  "  Syphiloderma  Papulatum  Circinatum. "  Journal 
Cutan.  and  Vener.  Dis.,  1883,  p.  15. 

BALLOCH,  E.  A.  "The  Relative  Frequency  of  Fibroid  Processes  in  the 
Dark  Skinned  Races."  Med.  News,  1894,  p.  29. 

BRODNAX,  B.  H.  "Color  of  Infant  Negroes.  "  Mississippi  Med.  Record, 
1903,  p.  174. 

BYERS,  J.  W.  "Diseases  of  the  Southern  Negro."  Med.  and  Surg. 
Reporter,  1888,  p.  734. 

CARTER,  H.  R.  "Manifestations  of  Syphilis  among  Negroes."  Report 
U.  S.  Marine  Hospital,  1882-3,  P-  I3I- 

Census  of  1900.     Supplementary  Analysis  and  Derivative  Tables,  p.  185. 

CORLETT,  W.  T.     Brit.  Med.  Jour.,  1906,  p.  839. 

CORSON,  E.  R.  "The  Vital  Equation  of  the  Colored  Race  and  its  Future 
in  the  United  States."  The  Wilder  Quarter  Century  Book,  p.  115. 

CORSON,  E.  R.  "Syphilis  in  the  Negro.  Its  Bearing  on  the  Race  Prob- 
lem." Am.  Jour.  Dermatol.,  1906,  p.  305. 

DIXON,  J.  S.  "Syphilis  in  the  Negro  as  Differing  from  Syphilis  in  the 
White."  Southern  Practitioner,  1879,  p.  64. 

DYER,  I.     Trans.  Louisiana  State  Med.  Soc.,  1895,  p.  257. 

Fox,  G.  H.     Brit.  Med.  Jour.,  1906,  p.  839. 

GILCHRIST,  T.  C.  " Blastomycetic  Dermatitis  in  the  Negro."  Brit. 
Med.  Jour.,  1902,  p.  1321. 

GILCHRIST,  T.  C.  "Two  Unusual  Cases  of  Annular  Syphilides  in  Ne- 
groes." Mary.  Med.  Jour.,  1900,  p.  200. 

HECHT,  D.  O.  "Tabes  in  the  Negro."  Am.  Jour.  Med.  Sci.,  1903, 
P-  705- 

HOFFMAN,  F.  L.  "Race  Traits  and  Tendencies  of  the  American  Negro." 
Pub.  Am.  Econom.  Assoc.,  vol.  xi.,  pp.  1-329. 


PLATE  IX— To  Illustrate  Dr.  Howard  Fox's  Article. 


FIG.  1. 


FIG.  2. 


PLATE  X— To  Illustrate  Dr.  Howard  Fox's  Article. 


FIG.  5. 


FIG.  6. 


PLATE  XI— To  Illustrate  Dr.  Howard  Fox's  Article. 


FIG.  7. 


I 


FIG.  8. 


FIG.  9. 


FIG.  10. 


PLATE  XII— To  Illustrate  Dr.  Howard  Fox's  Article. 


FIG.  12. 


DERMATOLOGICAL  CONGRESS  227 

HOFFMAN, F.L.    "Vital  Statistics  of  the  Negro.  "    Med.  News,  1894,  p. 320. 

HYDE,  J.  N.  "Influence  of  Light  in  Production  of  Cancer  of  the  Skin. 
Am.  Jour.  Med.  Sci.,  1906,  p.  i. 

JOHNSTON,  C.     Trans.  Am.  Surg.  Assoc.,  vol.  v.,  p.  265. 

JULLIEN,  L.     Maladies  Veneriennes,  p.  704. 

KINLOCH,  R.  A.     Trans.  Am.  Surg.  Assoc.,  vol.  v.,  p.  271. 

LOFTON,  L.  "Multiple  Chancre  in  the  Negro."  Am.  Jour.  Dermatol., 
1903,  p.  263. 

MATAS,  R.  "The  Surgical  Peculiarities  of  the  Negro."  Trans.  Am. 
Surg.  Assoc.,  vol.  xiv.,  p.  483. 

McHATTON,  H.  "The  Sexual  Status  of  the  Negro — Past  and  Present." 
Am.  Jour.  Dermatol.,  1906,  p.  7. 

MORISON,  R.  B.  "Personal  Observations  on  Skin  Diseases  in  the  Negro." 
Trans.  Am.  Dermatol.  Assoc.,  1888,  p.  29. 

MORROW,  P.  A.     Atlas  of  Skin  and  Venereal  Diseases,  p.  70. 

MURRELL,  T.  E.  Trans.  9th  Intemat.  Med.  Cong,  at  Washington,  1887. 
vol.  iii.,  p.  817. 

MURRELL,  T.  E.  "Syphilis  in  the  Negro.  Its  Bearing  on  the  Race 
Problem."  Am.  Jour.  Dermatol.,  1906,  p.  305. 

OTKEN,  C.  H.     The  Ills  of  the  South. 

POWELL,  W.  "Syphilis  in  the  Negro  as  Differing  from  Syphilis  in  the 
White  Race."  Trans.  Mississippi  State  Med.  Assoc.,  1878,  p.  76. 

PRINGLE.     Pictorial  Atlas  of  Skin  Dis.     Part  II.,  p.  40. 

PUSEY,  W.  A.     The  Principles  and  Practice  of  Dermatology,  p.  534. 

QUILLIAN,  D.  D.  "Racial  Peculiarities  a  Cause  of  the  Prevalence  of 
Syphilis  in  Negroes."  Am.  Jour.  Dermatol.,  1906,  p.  277. 

RICHARDSON,  T.  G.     Trans.  Amer.  Surg.  Assoc.,  vol.  v.,  p.  266. 

RUFZ.  "Note  sur  la  frequence  et  la  diversity  des  maladies  de  la  peau 
a  la  Martinique."  Bulletin  de  I'Academie  Imperiale  de  Medicine,  1858, 
p.  1051. 

SCHEPPEGRELL,  W.  "Comparative  Pathology  of  the  Negro  in  Diseases 
of  the  Nose,  Throat,  and  Ear."  Annals  of  Ophthal.  and  Otol.,  1895,  p.  589. 

SCHEPPEGRELL,  W.  "Keloid  Tumors  of  the  External  Ear."  N.  Y. 
Med.  Jour.,  1896,  p.  510. 

SIMONOT.     Bulletin  de  la  Soc.  d'Anthrop.,   1862,  p.   140. 

STELWAGON,  H.  W.     Diseases  of  the  Skin,  p.  743. 

TAYLOR,  R.  W.     Clinical  Atlas  of  Venereal  and  Skin  Diseases,  p.  122. 

TAYLOR,  R.  W.  "On  a  Peculiarity  of  the  Papular  Syphilide  of  the 
Negro."  Am.  Jour.  Syph.  and  Dermatol.,  1873,  p.  107. 

TIFFANY,  L.  McL.  "Comparison  between  the  Surgical  Diseases  of  the 
White  and  Colored  Races."  Trans.  Am.  Surg.  Assoc.,  vol.  v.,  p.  26. 

WILSON,  E.     Portraits  of  Diseases  of  the  Skin,  plate  A.  N. 

WHITE,  J.  C.  "Variations  in  Type  and  Prevalence  of  Skin  Disease." 
Trans.  Inter.  Med.  Cong.,  Philadelphia,  1876,  p.  665. 

WHITE,  J.  C.  "Dermatitis  Venenata,  a  Supplemental  List."  Jour. 
Cut.  Dis.,  1903,  p.  435. 

YANDELL,  D.  W.     Trans.  Am.  Surg.  Assoc.,  vol.  v.,  p.  270. 

Discussion 
DR.  ISADORE  DYER,  of  New  Orleans,  said  the  subject  of  skin 


228  SIXTH  INTERNATIONAL 

diseases  in  the  negro  was  one  which  must  appeal  to  all,  whether 
specialist  or  not,  who  lived  in  the  southern  part  of  this  country, 
and  who  came  in  touch  with  the  inhabitants  of  the  cities  of  Central 
and  South  America. 

Dr.  Fox's  paper  should  awaken  the  interest  of  the  profession, 
in  this  country,  at  any  rate,  to  the  need  of  studying  skin  diseases 
in  the  negro  in  distinction  to  those  observed  in  the  white  race. 
The  social  condition  of  the  negro  in  the  South  was  vastly  inferior 
to  his  condition  in  the  North,  and  for  that  reason  a  comparison  of 
statistics  bearing  on  this  subject  between  these  two  sections  of 
the  country  would  be  of  little  value.  In  the  South,  the  negro  as 
a  rule  did  not  apply  for  treatment  for  a  skin  condition  unless  it 
was  disfiguring  or  caused  him  suffering.  It  was  not  unusual 
to  have  a  negro  present  himself  for  some  venereal  disease,  and 
reveal,  upon  examination,  a  variety  of  parasitic  and  other  skin 
lesions. 

Dr.  Dyer  said  the  annular  syphilide,  as  seen  in  the  negro, 
especially  in  young  children,  was  many  times  partly  vesicular. 
There  was  an  arc  of  the  circle  which  was  quite  markedly  vesicular 
in  type.  The  observation  had  been  made  in  New  Orleans  that 
perhaps  the  only  malignant  type  of  syphilis  seen  there  occurred 
in  the  negro;  only  exceptionally  in  the  white.  Coming  from  a 
section  of  the  country  where  the  negro  population  was  so  largely 
represented  as  in  Louisiana,  forming  probably  one-quarter  of 
the  whole  population,  he  again  wished  to  emphasize  the  impor- 
tance of  a  more  careful  study  of  skin  diseases  among  the  blacks. 
There  were  many  points  in  the  appearance  of  the  lesions,  their 
color,  etc.,  which  had  heretofore  not  been  described.  Finally, 
he  wished  to  thank  Dr.  Fox  for  the  enlightenment  and  stimulation 
his  paper  would  bring  to  those  who  were  working  along  these  lines. 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  said  he  was  very  much 
interested  in  this  subject,  coming,  as  he  did,  from  a  city  in  which 
there  were  some  forty  thousand  negroes.  He  could  readily  see  how 
the  subject  was  beset  with  all  sorts  of  difficulties.  The  first  question 
to  be  answered  in  regard  to  the  relative  frequency  of  certain  skin 
diseases  in  this  race  was,  What  is  a  negro?  Properly  speaking, 
and  to  get  the  facts  strictly  correct,  the  investigation  should  have 
been  limited  to  the  pure  negroes  on  one  side,  and  the  pure  whites 
on  the  other.  This,  however,  would  be  impracticable,  as  there 
was  more  or  less  white  blood  in  so  many  members  of  the  black 
race.  These  patients  practically  did  not  figure  in  private  practice, 
and  in  dispensary  practice  they  did  not  present  themselves  in 


DERMATOLOGICAL  CONGRESS  229 

anything  like  the  proportion  that  one  would  expect.     In  many 
instances  they  treated  themselves,  or  remained  untreated. 

Dr.  Grindon  said  he  was  surprised  to  hear  that  syphilis  was 
milder  in  the  negro  than  in  the  white.  His  own  experience  had 
led  him  to  believe  the  opposite  to  be  the  fact.  Among  conditions 
which  he  had  found  more  common  in  the  black  were  the  papillary 
form  of  the  tubercular  syphilide  and  the  annular  papular  syphi- 
lide.  Dermatitis  papillaris  capillitii  he  had  only  seen  in  the  black. 
Psoriasis  he  had  witnessed  once  in  the  negro,  and  that  a  doubtful 
case. 


GANGR^ENA  CUTIS  HYSTERICA 
BY  DR.  HARVEY  P.  TOWLE,  OF  BOSTON 

That  jaffection  variously  named  Hysterical  Gangrene  of 
the  Skin,  Spontaneous  Gangrene,  Multiple  Neurotic  Gangrene, 
etc.,  offers  many  difficulties  in  its  diagnosis.  After  excluding 
the  cases  due  to  bacterial  infection,  arterio-sclerosis,  and  or- 
ganic disease  of  the  nervous  system,  there  remains  a  number 
of  cases  some  of  which  are  known  to  have  been  self-inflicted. 
Whether  those  cases  not  demonstrated  to  be  self-inflicted 
should  receive  a  separate  classification  has  given  rise  to  much 
discussion.  The  following  conspicuously  illustrate  the  diffi- 
culty of  the  diagnosis  of  an  artificial  eruption  when  no  positive 
proof  can  be  found. 

CASE   i.     Female,  16. 

F.  H.  Mother  died  of  "lung  trouble."  Father  died  of 
heart  disease. 

P.  H.     Negative. 

Present  Illness:  In  February,  1904,  the  patient  cut  her 
right  forefinger  with  a  piece  of  glass.  Four  or  five  days  later 
she  suddenly  began  to  have  pain  which  radiated  from  the 
wound  up  the  arm  to  the  shoulder.  Within  fifteen  minutes 
a  small  black  spot  appeared  on  the  end  of  the  right  forefinger 
which  spread  until  the  whole  skin  over  the  terminal  phalanx 
was  black.  The  pain,  intense  at  first,  after  the  color  change 
had  reached  its  height  grew  less  intense,  but  did  not  disappear 
entirely.  The  next  day  she  went  to  the  Surgical  Out-Patient 
Department  of  the  Boston  City  Hospital  for  treatment. 


23o  SIXTH  INTERNATIONAL 

"They  scraped  it  [the  spot]  and  sent  her  home."  The  spot 
was  treated  with  various  applications  and  later,  ' '  because  the 
bone  had  no  flesh  on  it  and  was  of  a  brownish  color,"  was 
scraped  a  second  time.  After  two  months'  treatment  at  the 
Boston  City  Hospital  the  patient  went  to  the  Homeopathic 
Hospital  when,  she  said,  "the  finger  had  grown  black  to  the 
second  joint  and  hurt  terribly."  May  16,  1904,  she  came 
to  the  Surgical  Out-Patient  Department  of  the  Massachusetts 
General  Hospital.  There  was  at  this  time  on  the  palmar 
surface  of  the  end  of  the  right  index  finger  an  ulcer  with  round 
contour  and  concave  surface  whose  base  was  formed  by  the 
exposed  phalangeal  bone.  There  was  no  apparent  attempt 
at  healing  and  no  induration  or  inflammatory  thickening  of 
the  edges  of  the  ulcer  or  of  the  joint.  On  the  next  day  the 
terminal  phalanx  was  removed  under  ether  and  the  stump 
covered  in  by  a  flap  taken  from  the  back  of  the  finger.  Three 
days  later  the  wound  showed  slight  signs  of  infection  which 
subsided  quickly.  The  wound  was  sluggish  and  was  not 
completely  healed  until  June  i3th,  about  four  weeks  after 
the  operation.  Meanwhile  the  stump  had  become  painful, 
apparently  from  the  tight  flap.  June  21,  1904,  the  patient 
was  discharged  well. 

June  23,  1904,  she  returned  with  the  wound  broken  down 
a  second  time.  June  25th,  the  second  phalanx  was  removed. 
After  the  operation  the  finger  became  swollen,  but  not  red 
or  painful.  The  pain  became  so  intense  that  on  July  12, 
1904,  she  was  referred  to  the  Nerve  Department  for  treatment. 
Their  notes  say  that  "there  was  present  on  the  side  of  the 
finger  end  a  small,  necrotic,  dark-colored  area  the  size  of  a  pea, 
with  a  moist  center.  This  area  was  not  especially  associated 
with  the  flap.  Diagnosis  neuritis."  This  lesion  persisted 
until  the  last  of  September,  1904.  When  the  patient  re- 
turned October  3,  1904,  the  amputation  wound  was  found 
to  be  healed,  but  the  stump  was  still  painful  and  tender.  The 
circulation  of  the  hand  was  poor. 

Her  next  visit  was  made  to  the  Nerve  Department  No- 
vember 3,  1904,  when  she  had  a  third  lesion  higher  up  than 
the  two  preceding.  (Plate  xiii,  Fig.  i.)  According  to  her 
story,  at  about  one  P.M.  of  the  preceding  day,  a  small  black 


DERMATOLOGICAL  CONGRESS  231 

spot  had  suddenly  appeared  which  continued  to  increase 
until  it  was  double  its  original  size.  "  There  was  over  the 
metacarpo-phalangeal  joint  a  dry,  gangrenous  area  slightly 
smaller  than  a  ten-cent  piece.  This  area  was  surrounded  by 
two  narrow  zones,  the  inner  of  a  whitish  color  and  the  outer 
pale  red.  The  whole  hand  was  cold  and  damp  and  "the 
girl  shrinks  from  any  attempt  to  touch  it. "  An  X-ray  pho- 
tograph showed  a  marked  atrophy  of  the  phalanx.  The 
gangrenous  area  continued  to  spread  accompanied  by  severe 
pains  shooting  up  the  arm  and  across  the  shoulder. 

November  8,  1904,  the  patient  was  transferred  to  the  Skin 
Department,  and  November  10,  1904,  was  admitted  to  the 
ward  for  diseases  of  the  skin.  The  record  states  that  at  the 
time  of  admission  "there  was  present  on  the  back  of  the  right 
hand  at  the  base  of  the  index  ringer  and  extending  over  on  the 
inner  surface  an  irregular  ulcerated  lesion  one-half  inch  by 
one  inch  in  diameter.  Its  shape  was  roughly  quadrilateral. 
Its  edges  were  of  a  wavy  outline,  not  elevated  above  the 
surrounding  skin  and  sloped  slightly  toward  the  centre. 
The  base  of  the  ulcer  was  slightly  depressed  below  the  sur- 
rounding surface  and  was  covered  with  a  homogeneous,  brown- 
ish, almost  blackish,  crust.  The  inner  half  of  the  right  hand 
from  the  knuckle  to  the  wrist  was  swollen  and  slightly  ery- 
thematous.  There  was  marked  tenderness  on  pressure  along 
a  line  drawn  from  the  forefinger  up  the  arm." 

The  patient  was  an  anaemic,  rather  dull  appearing  girl, 
indifferent  to  her  skin  affection  except  that  the  general  be- 
wilderment as  to  its  nature  appeared  to  afford  her  much 
satisfaction.  No  disease  of  any  of  the  internal  organs  could 
be  discovered.  Nothing  abnormal  was  found  in  the  blood- 
vessels, and  there  was  no  evidence  of  any  organic  disease  of 
the  nervous  system. 

The  later  records  state  that  the  ulcer  had  increased  slightly 
in  size  when,  November  i2th,  a  stiff,  starched  dressing,  which 
could  not  be  easily  removed  by  the  patient,  was  put  over  the 
lesion.  Two  days  later  this  sealed  dressing  showed  evident 
signs  of  manipulation.  From  November  1 2th  to  December  ist, 
the  ulcer  remained  in  the  stiff  dressing  continuously  except 
that  it  was  exposed  now  and  then  for  observation  and  then 


23a  SIXTH  INTERNATIONAL 

immediately  redressed.  Without  other  treatment  the  ulcer 
cleaned  up  promptly  and  by  December  ist  had  healed  except 
for  one  small  superficial  area.  The  sealed  bandage  was  then 
replaced  by  a  simple  protective  dressing  under  which  the 
ulcer  continued  to  heal  rapidly.  December  8th,  it  was  prac- 
tically well,  and  the  patient  was  told  that  she  would  be 
discharged  on  the  next  day. 

When  the  dressing  was  removed  the  next  morning  there 
was  exposed  a  round  superficial  ulcer  about  one-third  of  an 
inch  in  diameter.  That  same  night  the  patient,  who  had 
been  left  alone  with  the  thermometer  a  few  minutes,  developed 
an  apparent  temperature  of  101  degrees.  As  there  were  no 
other  symptoms  accompanying,  the  nurse  immediately  re- 
placed the  thermometer,  remaining  beside  the  bed  meanwhile. 
The  temperature  was  now  98.4  degrees.  The  patient  denied 
tampering  with  the  thermometer.  In  searching  for  an  ex- 
planation of  the  unaccountable  rise  it  was  discovered  that 
if  a  thermometer  was  inserted  into  the  hot  air  register  it  would 
rise  to  101  degrees  in  a  very  few  seconds.  Although  the 
patient  had  had  the  time  and  the  opportunity  it  cannot,  of 
course,  be  proved  that  she  had  done  this.  The  newly  de- 
veloped ulcer  was  enclosed  in  a  sealed  dressing  and  was  healed 
in  nine  days.  The  patient  was  again  told  that  she  would  be 
discharged  the  next  day. 

For  the  second  time  the  announcement  of  her  coming 
discharge  from  the  hospital  was  followed  by  the  appearance 
of  new  lesions  during  the  night.  The  next  morning  there 
was  found  on  the  site  of  the  old  lesion  an  elongated,  superficial 
excoriation  with  red,  smooth  base,  secreting  much  serum, 
and  with  jagged,  torn  edges  which  suggested  mechanical 
trauma.  According  to  the  patient,  the  lesion  had  appeared 
suddenly  during  the  night,  without  subjective  symptoms 
and,  so  far  as  she  knew,  without  cause.  Under  a  sealed 
dressing  the  wound  had  about  healed  when  the  patient  con- 
tracted diphtheria,  and  was  transferred  to  the  contagious 
hospital,  December  25,  1904. 

She  was  not  seen  again  until  March  4,  1905,  when  she  re- 
turned to  the  Surgical  Out-Patient  Department  with  an 
irregular  ulcer  on  the  inner  side  of  the  right  index  finger, 


DERMATOLOGICAL  CONGRESS  233 

one-half  inch  in  diameter  and  covered  with  a  blackish  crust. 
This,  she  said,  had  developed  the  day  before  within  five  or 
ten  minutes.  March  18,  1905,  the  remaining  phalanx  was 
amputated.  March  24th,  the  stitches  were  removed  and  she 
was  discharged  from  the  hospital  with  the  wound  clean  and 
solid.  One  week  later  a  black,  dry,  gangrenous  area  about 
one-half  inch  in  diameter  developed  on  the  inner  side  of 
the  amputation  scar.  (Plate  xiii,  Fig.  2.)  April  i3th,  the 
gangrenous  area  was  curetted  and  two  inches  of  the  radial 
nerve  were  excised.  A  recurrence  was  not  prevented,  however, 
and  on  April  22d  she  was  again  admitted  to  the  surgical  ward, 
where  'the  ulcer  gradually  healed  under  hot  and  cold  douches 
and  massage.  During  her  stay  in  the  hospital  she  complained 
greatly  of  sleeplessness  and  loss  of  appetite.  May  gih  she  was 
discharged,  but  returned  on  May  25,  1905,  to  the  Surgical 
Out-Patient  Department,  saying  that  since  her  discharge  from 
the  ward  the  black  spot  had  continued  to  spread.  She  was 
readmitted  to  the  hospital  and  the  median  nerve  was  stretched. 
For  two  or  three  days  after  the  operation  catheterization  was 
necessary.  The  operation  wound  healed  readily  and  on  May 
3ist  she  was  again  discharged  to  the  Surgical  Out-Patient 
Department.  She  continued  to  complain  of  the  pain  in  her 
shoulder.  The  ulcer  also  continued  to  spread  until  by  June  24, 
1905,  it  had  exposed  the  dorsal  tendon.  After  curetting 
it  began  to  close  in  slowly  until,  July  29,  1905,  it  was  finally 
healed. 

During  her  various  stays  in  the  hospital  the  patient  had 
always  complained  greatly  of  the  tenderness  of  the  ulcers. 
It  was  very  noticeable,  however,  that  when  not  under  ob- 
servation the  patient  was  able  to  use  the  hand  in  a  manner 
which  did  not  bear  out  her  assertion  of  their  great  tenderness. 
Further,  if  her  attention  could  be  diverted  while  under  ex- 
amination the  ulcer  could  be  handled  freely  without  causing 
any  expression  of  pain. 

The  patient  continued  to  return  from  time  to  time  because 
of  pain  in  the  hand  and  arm.  No  more  ulcers  developed  on 
the  hand,  but,  March  27,  1907,  she  came  with  a  shallow  ulcer 
over  the  right  tendon  Achilles,  which  healed  promptly  and 
never  recurred. 


234  SIXTH  INTERNATIONAL 

She  was  seen  for  the  last  time  April  29,  1907,  when  she 
reported  that  there  had  been  no  more  outbreaks.  "She 
complained  of  pain  for  the  last  six  months  in  the  lower  left 
side  at  the  time  of  the  menstrual  periods  and  also  of  occasional 
diarrhoea  and  vomiting.  Nothing  was  found  on  physical 
examination  except  a  slight  leucorrhoea.  " 

CASE  i.  Summary.  Trauma.  First  manifestation  after 
four  or  five  days  at  site  of  wound.  Eruption  preceded  and 
accompanied  by  pain  radiating  from  the  part.  Abrupt 
appearance  of  black  spot  quickly  forming  slough.  Ulcer 
refused  to  heal.  Spread  downwards  to  bone.  No  inflamma- 
tory thickening  or  induration.  Recurrences  higher  up  at 
varying  intervals  pursuing  same  course  as  first.  Successive 
amputations  of  first  and  second  phalanges  failed  to  cure. 
First  lesion  round,  later  ones  irregular;  once  accompanied 
by  swelling  and  hyperaemia.  Healing  under  closed  dressing. 
Feigned  temperature.  Twice  lesions  recurred  during  the  night 
coincidently  with  the  announcement  of  her  approaching 
discharge.  Amputation  of  third  phalanx  and  later  excision 
of  piece  of  radial  nerve  failed  to  check  the  recurrences, 
Was  also  new  lesion  after  stretching  of  median  nerve.  Spon- 
taneous cessation  of  process  after  duration  of  one  and  one-half 
years.  Eruption  limited  to  hand  and  forefinger.  Slight 
signs  of  hysteria.  No  syringomyelia  or  arterio-sclerosis. 
Internal  organs  normal.  Patient  not  detected.  Later,  vom- 
iting and  diarrhoea  with  the  menses. 

CASE  2.  Female,  18.  The  patient  was  admitted  to  the 
Skin  Ward  of  the  Massachusetts  General  Hospital,  September 
13,  1904. 

It  was  difficult  to  obtain  a  good  history  from  the  patient, 
as  apparently  she  alternately  resented  the  questioning  and 
amused  herself  by  making  indefinite  and  contradictory  replies. 
The  family  history  and  the  previous  history  were  negative. 
Two  years  ago  the -patient  was  vaccinated  on  the  left  upper 
arm.  The  inoculation  went  through  the  usual  cycle  and 
healed.  A  few  weeks  later  a  small  red  spot  formed  on  the 
site  of  the  inoculation,  which  spread  gradually  and  finally 


DERMATOLOGICAL  CONGRESS  235 

broke  down  and  formed  a  good-sized  ulcer.  Under  simple 
treatment  this  ulcer  healed,  but  has  broken  down  again  several 
times  at  varying  intervals.  Two  months  after  vaccination 
a  second  ulcer  similar  to  the  first  appeared  in  the  bend  of  the 
elbow.  Since  then  there  have  been  continual  recurrences. 

The  patient  was  a  well-developed  and  nourished  young 
woman.  Nothing  abnormal  was  found  in  the  heart,  lungs, 
kidneys,  or  other  organs.  No  temperature  nor  pulse.  There 
were  signs  of  hysteria  present.  Except  on  the  left  upper 
extremity  the  skin  of  the  body  was  normal. 

On  the  outer  aspect  of  the  left  upper  arm  was  an  irregu- 
larly circumscribed  ulceration  about  two  and  one-half  inches 
in  diameter.  Its  edges  were  healthy  and  raised  very  slightly. 
The  outermost  half-inch  of  the  ulcer  was  superficial  and  the 
base  clean  and  granulating.  The  area  within  this  outer  zone 
was  deeper,  irregularly  quadrilateral  in  shape,  with  gently  slop- 
ing edges,  and  of  a  bluish-yellow,  necrotic  hue.  On  the  outer 
surface  of  the  left  elbow  was  an  elongated,  superficial  ulceration 
about  one-half  by  two  inches  in  dimension,  dark-colored  and 
shiny.  There  was  also  a  bean-sized  crusted  lesion  just  below 
the  larger  ulcer  on  the  upper  arm.  (Plate  xiii,  Fig.  3.) 

The  sites  of  the  former  lesions  were  marked  by  several 
small  scars  and  by  a  macular,  rather  purpuric-looking  area 
on  the  extensor  surface  of  the  upper  fourth  of  the  left  forearm. 

The  patient  was  discharged  at  her  own  request  October 
4,  1904.  While  in  the  hospital  the  ulcer  at  the  bend  of  the 
elbow  had  nearly  healed,  the  large  ulcer  on  the  upper  arm 
had  closed  in  somewhat,  but  the  small  ulceration  on  the  upper 
arm,  after  partially  healing,  had  again  broken  down  and  at  the 
time  of  discharge  was  as  large  as  at  entrance. 

When  she  returned  to  the  O.  P.  D.  October  17,  1904,  it 
was  found  that  the  ulcer  on  the  upper  arm  had  grown  larger 
and  was  connected  with  a  smaller  lesion  just  below  it  by  a 
narrow,  superficial  abrasion.  The  surface  of  the  upper  lesion 
was  covered  by  a  dark  blood  crust,  while  the  skin  was  livid 
for  a  considerable  distance  around.  In  the  bend  of  the  elbow 
was  an  elongated,  superficial,  dark-colored  ulceration,  like 
the  upper  lesion,  surrounded  by  livid  tissue.  The  ulceration 
in  the  bend  of  the  elbow  had  healed  by  October  25th,  and  the 


236  SIXTH  INTERNATIONAL 

others  were  apparently  closing  in.  On  November  ist,  the 
patient  returned  with  fresh,  irregular,  jagged,  red  patches, 
extending  from  the  ulcers  on  the  upper  arm  around  to  the 
inner  surface  of  the  arm,  over  which  the  patient  complained 
of  tenderness.  The  scar  of  the  old  lesion  in  the  elbow  had 
broken  down  again.  The  arm  was  enclosed  in  a  sealed  bandage 
which  was  continued  until  November  26th.  Under  this  bandage 
the  large  upper  ulcer  healed  steadily.  The  small  ulcer  at  first 
diminished  in  size,  then  grew  deeper,  but  finally  began  to  heal. 
The  ulcer  at  the  bend  of  the  elbow  at  first  grew  shallower  and 
longer,  then  filled  in  and  contracted  rapidly.  All  the  ulcers 
promptly  became  cleaner  and  healthier-looking.  On  No- 
vember 8th,  while  having  the  dressing  removed,  the  patient 
suddenly  fainted.  Her  color  remained  good.  The  pupils 
were  dilated.  The  eyelids  fluttered  rapidly.  There  was 
slight  tremor  of  the  arms,  most  marked  on  the  right.  Un- 
consciousness was  not  complete.  Later  on  the  patient  stated 
that  she  had  had  similar  attacks  before  which  were  always 
preceded  by  a  "peculiar,  bad  feeling  in  her  stomach." 

From  November  26th,  when  the  sealed  dressing  was  omitted, 
onward  the  progress  was  so  unsatisfactory  that  the  patient 
was  readmitted  to  the  skin  ward  on  December  9,  1904.  At 
this  time  it  was  noted  that  "on  the  left  arm  at  the  insertion 
of  the  deltoid  the  epidermis  is  gone  over  an  area  2x2  inches 
in  its  widest  diameters,  with  a  short  peninsula  of  normal  skin 
on  its  lower,  inner  side.  For  about  one-half  inch  inward  the 
lesion  is  very  superficial,  nearly  level  with  the  surrounding 
skin,  and  grayish-pink  in  color.  Within  this  is  a  central  area 
of  irregular  contour  which  is  depressed  somewhat  below  the 
surface.  The  lower  portion  of  this  central  area  is  of  a  reddish 
color,  while  the  upper  portion  is  covered  with  a  brownish- 
black  deposit.  The  whole  lesion  is  moist.  The  surrounding 
skin  for  a  distance  varying  from  one-quarter  of  an  inch  to 
one  inch  is  of  a  slightly  dusky  hue.  One  inch  lower  down 
on  the  outer  aspect  of  the  arm  is  a  lesion  one-quarter  of  an 
inch  in  diameter  whose  periphery  is  slightly  elevated  and 
whose  centre  is  covered  with  a  dry,  grayish  crust.  Removal 
of  the  crust  exposes  a  smooth  surface  bathed  in  a  profuse, 
clear  secretion.  At  the  bend  of  the  elbow  is  a  dusky  area 


DERMATOLOGICAL  CONGRESS  237 

one  and  a  half  inches  wide  extending  across  the  arm.  In  its 
centre  is  an  elongated  ulceration  with  a  concave  base,  not 
especially  deep,  edges  not  elevated  nor  indurated.  The 
base  is  a  healthy  red,  secretes  serum  abundantly,  and  bleeds 
easily. " 

December  nth,  the  patient  had  an  hysterical  attack,  during 
which  she  attempted  to  do  herself  injury.  Her  pulse  was 
normal  throughout.  No  temperature. 

"  On  the  morning  of  December  i4th,  the  back  of  the  left 
hand  and  the  arm  up  to  within  two  inches  of  the  elbow  was 
discovered  to  be  swollen  and  slightly  erythematous.  Three 
inches  below  the  elbow  on  the  outer  surface  of  the  arm  the 
skin  was  denuded  of  its  outer  layers  over  an  irregularly  tri- 
angular area,  one  and  one-half  inches  in  its  widest  part.  The 
surface  of  the  excoriation  was  smooth  and  red  and  its  edges 
jagged  and  irregular.  Just  below  and  adjoining  this  area 
was  a  cluster  of  vesicles  both  discrete  and  confluent.  When 
questioned  about  this  new  outbreak,  the  patient  at  first  said 
that  early  in  the  previous  evening  her  left  arm  began  to  pain 
and  a  black  spot  the  size  of  the  tip  of  the  finger  appeared 
which  within  an  hour  and  a  half  had  attained  the  size  of  a 
fifty-cent  piece.  But  later  she  said  that  the  eruption  began 
with  vesicles  of  various  sizes.  She  removed  the  top  from  the 
largest,  which  left  the  denuded  area  described. "  The  upper 
arm,  which  had  been  enclosed  in  a  starch  bandage,  remained 
unchanged.  Under  a  closed  dressing  the  ulcers  healed  very 
rapidly.  On  December  2  ist,  the  larger  upper  ulcer  was  covered 
with  healthy  granulations  and  had  diminished  to  less  than 
one-half  its  original  size,  while  the  smaller  ulcer  below  it  had 
practically  healed.  December  2  ist,  the  patient  left  the  hospital 
because  the  starched  bandage  was  replaced. 

The  girl  was  not  seen  again  until  February  23,  1905,  when 
she  returned  to  the  O.  P.  D.  with  the  ulcer  on  the  upper  arm 
in  about  the  same  condition  as  at  the  time  of  her  discharge 
from  the  hospital,  but  with  the  scar  of  the  old  ulcer  at  the  bend 
of  the  elbow  broken  down  again 

On  April  yth,  the  elbow  had  entirely  healed,  while  the  lesion 
on  the  upper  arm  was  about  one-half  smaller.  On  the  forearm 


238  SIXTH  INTERNATIONAL 

was  a  dusky-colored,  patch  of  two  days'  duration,  in  whose 
centre  was  a  pea-sized  circular  area  of  reddish-brown  with  a 
central,  pin's  head-sized  blackish  point.  April  25th  the  upper 
lesion  had  grown  more  superficial  and  was  covered  with  a 
brownish-black  crust  from  beneath  which  oozed  a  dark-colored 
discharge.  May  i,  1905,  the  patient  left  in  anger  because 
asked  if  she  had  caused  the  ulcers.  She  was  not  seen  again 
until  a  few  months  ago  (1907).  All  the  lesions  had  entirely 
healed  with  irregular  hypertrophic  scars.  She  reported  that 
there  had  been  no  outbreak  for  over  a  year. 

During  the  course  of  her  affection  the  patient  was  ex- 
amined several  times  by  the  neurologists  both  in  the  Out- 
Patient  Department  and  in  the  Skin  Ward,  but,  except  for 
hysteria,  nothing  abnormal  was  discovered  in  the  nervous 
system.  At  one  of  these  visits  to  the  Out-Patient  Department 
an  unsuccessful  attempt  was  made  to  hypnotize  the  patient. 
As  she  disappeared  immediately  after,  the  attempt  could  not 
be  renewed. 

SUMMARY.  Hysteria.  Trauma  followed  in  a  few  weeks 
by  first  eruption  on  site  of  wound.  Recurrences  on  site  and 
below  it,  but  never  above.  New  lesions  at  varying  intervals. 
Lesions  superficial.  Erythema  becoming  gangrenous;  ex- 
coriations; redness,  swelling,  vesicles  and  excoriations;  super- 
ficial unsymmetrical  ulcerations  with  crusts  usually  dark; 
livid  patches.  Healing  under  closed  dressings.  Dressing 
tampered  with.  Eruption  on  exposed  arm  and  hand  sparing 
the  part  protected  by  bandage.  Onset  of  eruption  sudden, 
generally  without  preceding  subjective  symptoms.  Course 
to  gangrene  rapid,  followed  by  slow  healing.  Irregularity 
of  form  of  lesions  marked.  Duration  of  process  about  three 
and  one-half  years.  Eruption  confined  to  left  arm.  Spread 
of  eruption  very  irregular,  jumping  about  from  place  to  place. 
Patient  viewed  outbreaks  with  complacency  and  was  pleased 
with  attention  attracted. 

CASE  3.  Female,  22.  This  patient  was  admitted  to  the 
Skin  Ward  of  the  Massachusetts  General  Hospital  November 
13,  1906.  It  was  impossible  to  obtain  a  satisfactory  history 
from  the  patient,  but,  fortunately,  I  was  able  to  confirm  and 


DERMATOLOGICAL  CONGRESS  239 

supplement  her  story  by  means  of  letters  received  from  her 
attending  physician  and  from  the  different  hospitals  in  which 
she  had  been  a  patient. 

Both  parents  died  when  she  was  a  child.  At  nine  years 
of  age  she  was  adopted.  The  cause  of  the  father's  death  is 
unknown.  In  the  case  of  the  mother,  although  one  hospital 
record  says  that  she  died  of  tuberculosis,  the  patient's  attending 
physician  says  that  the  cause  is  not  known. 

The  patient  says  of  her  previous  history  that  she  had 
always  been  well  up  to  the  time  of  the  present  affection.  On 
the  other  hand,  a  letter  states  that  she  was  "well  until  fifteen 
years  old,  when  she  began  to  have  sick  spells,  apparently 
of  acute  indigestion,  which  sometimes  confined  her  to  her 
bed  for  two  or  three  weeks. "  Further,  another  letter  states 
that  in  1904,  while  in  a  hospital  for  the  treatment  of  her  skin 
affection,  she  had  an  attack  of  appendicitis,  but  was  not 
operated  on.  Also  Dr.  Waterman,  of  the  Nerve  Department, 
obtained  from  the  patient  evidence  of  periods  of  amnesia. 

In  regard  to  the  present  illness,  all  accounts  agree  that  the 
starting-point  was  a  burn  by  steam  on  the  right  wrist  in  Janu- 
ary, 1903.  The  burn  was  treated  with  a  strong  solution  of  car- 
bolic acid  and  refused  to  heal,  so  that  in  March  she  consulted 
Dr.  -  — .  He  writes  that  at  that  time  "there  was  an  ulcer 
one  inch  in  diameter  covered  with  a  greenish  exudate,  situated 
over  the  base  of  the  ulna  on  the  anterior  surface.  After  four 
weeks  (April)  the  ulcer  healed.  In  July  the  scar  was  re- 
opened by  a  pin-prick  and  underwent  a  course  similar  to  the 
first,  but  attended  with  greater  pain,  which  ascended  to  the 
shoulder  and  neck.  The  wound  showed  no  inclination  to 
heal.  After  eight  weeks'  treatment  it  was  excised. "  (The 
patient  stated  that  the  wound  was  excised  in  November  and 
that  prompt  healing  followed  the  operation.)  "About  two 
weeks  later  another  ulcer  occurred  about  half-way  to  the  elbow, 
which  was  also  excised.  Healing  by  first  intention. "  De- 
cember 24,  1903,  the  patient  entered  a  hospital,  whose  record 
follows:  "On  admission  there  was  an  ulcer  over  the  lower  end 
of  the  ulna,  which  she  says  was  caused  by  carbolic  acid  some 
months  before.  Above  this  in  a  straight  line  up  the  arm  were 
four  other  ulcersVhich  she  said  had  appeared  later  and  without 


24o  SIXTH  INTERNATIONAL 

known  cause.  These  were  dressed  with  various  applications 
for  a  time  without  much  result.  Then  she  was  given  X-ray 
treatment,  under  which  they  improved  rapidly.  The  patient 
was  discharged  at  her  own  request  at  the  end  of  two  weeks 
and  before  the  ulcers  were  entirely  healed. " 

The  physician  already  quoted  takes  up  the  story  again 
at  this  point.  He  says  that  "in  January,  1904,  four  ulcers 
appeared  simultaneously  in  the  bend  of  the  right  elbow,  similar 
to  the  former  lesions,  and  healed  slowly.  At  the  same  time 
ulcers  appeared  on  each  instep  and  were  excised. "  (Ac- 
cording to  the  patient's  story,  new  areas  appeared  on  the  inner 
surface  of  the  right  elbow  and  left  wrist  about  February  ist. 
The  failure  to  heal  them  with  X-ray  was  followed  by  their 
excision.  She  does  not  mention  the  lesions  on  the  instep). 
"Up  to  this  time  the  lesions  had  all  been  characterized  by 
ulceration,  greenish  exudate,  and  slow  healing.  Now,  a  new 
variety  of  ulceration  followed,  which  was  characterized  by  its 
band  shape,  encircling  the  leg  above  and  below  the  knee. 
The  skin  took  on  a  blanched  appearance,  sloughed  with  a 
white  exudate  which  resembled  granulated  sugar.  In  April, 
1904,  ulcers  of  the  first  variety  with  a  greenish  exudate  ap- 
peared on  the  abdomen,  some  of  which  were  excised.  Other 
lesions  appeared  at  frequent  intervals. " 

June  3,  1904,  the  patient  entered  a  second  hospital,  at 
which  the  diagnosis  of  hereditary  syphilis  was  made.  She 
was  given  antisyphilitic  treatment,  under  which  the  lesions 
improved  very  rapidly.  June  18,  1904,  she  was  discharged. 

After  nearly  a  year  of  freedom  from  further  outbreaks, 
her  physician's  letter  continues:  "In  May,  1905,  a  blister  of 
the  right  index  ringer  was  followed  by  the  appearance  of 
gangrene,  which  was  excised.  As  there  was  not  tissue  enough 
to  cover  the  wound,  it  was  left  to  granulate.  The  granulations 
appeared  healthy,  but  broke  down  in  a  few  days.  The  fol- 
lowing necrosis  eventually  involved  the  metacarpal  bone, 
which  was  therefore  removed  in  August,  1905.  Skin  grafting 
to  close  the  wound  was  successful.  Since  this,  ulcers  have 
continued  to  appear  in  quick  succession  in  various  parts. " 

Two  weeks  before  entrance  to  the  Massachusetts  General 
Hospital  three  lesions  of  one  week's  duration  which  had  ap- 


DERMATOLOGICAL  CONGRESS  241 

peared  on  the  upper  portion  of  the  right  forearm  were  excised. 
The  patient  said  of  the  evolution  of  the  process  that  the  lesions 
came  independently  of  any  trauma  and  were  always  preceded 
by  a  smarting  of  the  area  about  to  become  affected.  The 
skin  then  turned  red,  changed  to  green  and  finally  became  dark 
colored.  The  onset  was  always  sudden.  The  patient  also 
stated  that  an  ordinary  wound  always  healed  rapidly. 

The  physical  examination  made  after  entrance  to  the  Skin 
Ward  of  the  Massachusetts  General  Hospital  showed  no 
organic  disease  of  the  internal  organs  or  the  nervous  system. 
The  patient  was  a  quiet,  intelligent  woman,  well  developed 
and  rather  stout.  There  was  nothing  suspicious  in  her  manner, 
but  concerning  her  affection  she  was  inclined  to  be  reticent, 
and  her  answers  were  contradictory.  The  skin  of  the  arms 
and  legs  and  especially  of  the  front  and  sides  of  the  abdomen 
was  the  seat  of  very  numerous  scars  of  all  lengths  from  one 
inch  to  one  extending  from  the  front  of  the  abdomen  down 
over  the  side  which  measured  eight  inches.  The  scars  all 
looked  healthy,  firm,  and  white.  Some  were  smooth,  some 
were  slightly  hypertrophic.  (Plate  xiv,  Fig.  4.) 

On  the  right  forearm  were  two  incised  wounds  which  were 
nearly  healed.  There  were  also  three  excoriations,  said  to  be 
a  beginning  eruption,  lying  together,  which  were  superficial, 
with  jagged  edges  and  central  brownish  crusts.  Their  bases 
were  inclined  upward  from  the  deeper  proximal  end  toward 
the  hand  where  they  became  so  superficial  as  to  be  nearly 
level  with  the  skin.  Their  appearance  suggested  gouging 
with  the  finger-nails.  On  the  abdomen  also  were  several 
lesions  of  a  similar  character. 

No  new  eruption  developed  while  the  patient  was  in  the 
hospital,  and  under  simple  protective  dressings  the  lesions 
present  at  entrance — which  were  said  to  be  similar  to  those 
of  previous  outbreaks — were  entirely  healed.  November 
28,  1906,  the  patient  was  discharged  well. 

During  her  stay  in  the  hospital  the  patient  was  thoroughly 
examined  several  times  by  the  physicians  from  the  neurological 
department.  They  could  detect  no  present  signs  of  hysteria, 
although  they  considered  that  the  history  strongly  indicated 
that  the  patient  had  had  hysterical  attacks  during  the  past 

VOL.   J. — 16 


242  SIXTH  INTERNATIONAL 

two  years.  Among  other  things  they  discovered  that  there 
were  several  short  periods  about  which  the  patient  could 
remember  nothing.  •  No  signs  of  organic  disease  or  disturb- 
ances of  function  of  any  part  of  the  nervous  system  were  ever 
found. 

SUMMARY.  Female,  22.  History  of  hysteria.  Memory 
of  certain  periods  lacking.  Preceding  trauma.  First  erup- 
tion in  the  neighborhood.  Upward  spread.  For  a  time 
limited  to  one  part,  then  occurring  elsewhere,  but  always  on 
accessible  parts.  No  relation  to  nerve  distribution.  Spread 
erratic.  Eruption  bilateral  but  not  symmetrical.  Onset 
sudden.  Outbreaks  preceded  by  smarting  or  pain.  First 
type  of  eruption  redness,  becoming  greenish,  then  forming 
gangrenous  ulcer.  Lesions  round.  Second  type — band  for- 
mation— blanching  of  skin,  slough,  white  granular  exudate. 
Healing  slow.  Crops  at  varying  intervals.  Numerous  lesions 
excised.  Wounds  always  healed  kindly.  Ulcers  healed  rap- 
idly under  protective  treatment.  No  outbreaks  while  under 
observation.  Lesions  symmetrical.  No  evidence  of  organic 
disease  of  internal  organs  or  of  nervous  system. 

CASE  4. — T.  R.,  male,  40,  married,  coachman. 

F.  H.,  16.  Father  died  of  old  age.  Mother  and  one 
sister  of  phthisis.  Nine  brothers  and  sisters  died  of  scarlet 
fever  and  typhoid. 

P.  H.  Scarlet  fever  in  childhood.  Otherwise  always  has 
been  well.  Habits  good.  Uses  neither  alcohol  nor  tobacco. 
Denies  venereal  infection. 

P.  I.  In  December,  1905,  the  end.  of  the  right  index 
finger  was  burned  by  a  spark  from  a  stove.  The  burn  refused 
to  heal  and  remained  open.  In  March,  1906,  it  became  in- 
fected. At  first  local,  the  infection  soon  spread  and  involved 
the  whole  finger,  the  back  of  the  hand  and  the  extensor  surface 
of  the  forearm  nearly  to  the  elbow.  These  areas  became 
greatly  swollen  and  inflamed  but  the  temperature  was  not 
high.  The  bone  of  the  terminal  phalanx  became  involved 
and  was  first  scraped  and  then  amputated  at  the  second  joint. 
The  stump  wound  healed,  but  three  weeks  later  became 
infected.  The  process,  as  before,  penetrated  deeply  and  the 


DERMATOLOGICAL  CONGRESS  243 

index  finger  was  now  amputated  at  the  metacarpo-phalangeal 
joint.  After  the  inflammation  in  the  hand  and  arm  had  sub- 
sided, the  skin  on  the  back  of  the  hand  and  the  outer  surface 
of  the  forearm  was  almost  entirely  replaced  by  a  thick  network 
of  scar-like  ridges  which  ran  in  all  directions,  here  and  there 
enclosing  normal  skin.  The  second  amputation  wound  healed 
in  six  or  seven  weeks. 

Following  the  inflammation  of  the  arm,  new  lesions  de- 
veloped on  the  hand,  at  the  site  of  the  amputation  wound, 
on  the  wrist,  on  the  inner  surface  of  the  forearm  near  the 
elbow,  and  one  on  the  inner  surface  of  the  upper  arm  just 
above  the  elbow.  These  showed  no  tendency  to  heal,  and 
were  accompanied  by  great  and  constant  pain  which  the  patient 
said  was  of  an  intermittent  character  and  radiated  up  the 
arm  to  the  shoulder  and  thence  over  the  adjacent  upper  chest 
on  the  right  side.  It  was  so  severe  that  his  general  condition 
suffered  because  it  prevented  sleep.  November  20,  1906,  he 
was  taken  to  a  private  hospital,  an  incision  made  in  the  right 
axilla,  and  the  nerve  stretched.  The  incision  wound  healed 
readily.  Just  prior  to  the  operation  he  was  examined  by  a 
prominent  neurologist  who  found  marked  hyperaesthesia 
of  the  whole  right  arm  and  the  right  side  of  the  chest  from  the 
shoulder  to  the  breast.  At  the  time  of  the  nerve-stretching 
there  was  present  over  the  metacarpo-phalangeal  joint  of  the 
second  finger  of  the  right  hand  an  ulcer  which  had  developed 
soon  after  the  amputation  of  the  finger.  On  the  right  wrist  was 
an  ulcer  about  the  size  of  a  quarter,  and  near  it  two  smaller 
lesions.  On  the  inner  surface  of  the  right  forearm  was  a 
moderately  large  lesion  and  on  the  right  upper  arm  above  the 
elbow  was  an  ulcer  nearly  two  and  one-half  inches  in  diameter. 
These  lesions  were  similar  in  character.  They  were  round  or 
oval,  covered  with  dark-colored,  almost  black,  crusts  of  varying 
thicknesses,  whose  upper  layers  were  dry  and  hard,  their  lower 
moist  and  gummy,  and  beneath  which  were  profusely  secreting, 
rather  superficial  ulcers.  Following  the  nerve-stretching, 
the  lesions  improved  and  healed  considerably,  the  smaller 
ones  even  disappearing.  But  progress  gradually  declined 
as  time  went  on  until  the  ulcers  finally  reverted  to  their  old 
sluggish  condition.  The  radiating  pain,  which  had  disappeared 


244  SIXTH  INTERNATIONAL 

after  the  operation,  returned  with  the  decline  in  the  process 
of  healing.  About  one  month  previous  to  his  admission  to 
the  Massachusetts  General  Hospital  there  was  a  new  and 
more  abundant  outbreak,  chiefly  over  the  right  upper  arm 
and  shoulder  with  a  few  ulcers  on  the  right  forearm.  Ac- 
cording to  the  history  obtained,  the  lesions  were  always  pre- 
ceded by  a  stinging  in  the  part  which  increased  to  actual 
pain.  Then  there  appeared  on  the  affected  area  a  small  black 
spot  which  slowly  increased,  attaining  in  one  month  about 
the  size  of  a  fifty-cent  piece.  There  was  more  or  less  constant, 
darting  pain,  worst  at  night  or  in  cold  weather.  Within  the 
past  few  days  a  few  new  lesions  have  appeared  on  the  dorsum 
of  the  right  foot.  The  patient  denied  the  use  of  any  irritant 
applications  on  the  lesions  except  alcohol.  Sleep  and  appetite 
have  been  poor  and  the  general  condition  has  not  been  good. 

The  man  was  admitted  to  the  Skin  Ward  of  the  Massa- 
chusetts General  Hospital,  February  26,  1907.  T.,  99;  P.,  93; 
R.,  18.  "He  was  well  developed,  but  rather  emaciated  and 
anaemic.  His  manner  was  quiet,  almost  taciturn,  but  watch- 
ful. When  observed  he  would  become  almost  immobile, 
but  when  alone  he  often  paced  the  floor,  played  a  tattoo  writh 
his  fingers,  or  indulged  in  other  minor  actions  indicative  of  a 
certain  restlessness.  The  tongue  was  clean;  the  teeth  in  fair 
condition;  the  mouth  and  throat  negative.  There  was  no 
glandular  enlargement.  The  heart  was  normal  in  position 
and  area.  There  were  no  murmurs  and  the  sounds  were 
clear.  Action  regular.  The  pulse  was  regular  and  of  good 
volume  and  tension.  There  was  no  evidence  of  any  disease 
of  the  arteries.  The  lungs  were  normal.  There  was  no 
tenderness  or  distension  of  the  abdomen,  and  its  organs  were 
normal.  The  reflexes  were  present  on  both  sides,  but  ex- 
aggerated on  the  left.  Urine  normal. 

The  examinations  by  Drs.  Putnam  and  Waterman  of  the 
Nerve  Department  showed  "diminished  sensation  over  the 
entire  right  side  sharply  bounded  by  a  line  a  little  to  the  left 
of  the  median  line.  Over  this  area  there  was  no  recognition 
of  pain.  There  was  also  loss  of  tactile  sense.  The  patient 
suffers  no  discomfort  from  touch  on  the  cornea  on  the  right 
side  nor  from  insertion  of  a  pin  into  the  right  nostril.  No 


DERMATOLOGICAL  CONGRESS  245 

sneezing.  Visual  reactions  not  tested.  There  is  evidence 
of  hysteria. " 

"The  eruption  was  confined  to  the  right  arm  and  hand 
and  to  the  dorsum  of  the  right  foot,  twelve  or  fourteen  lesions 
in  all.  At  the  site  of  the  amputation  scar  was  an  irregular 
lesion,  measuring  one  inch  by  two  and  one-half,  which  was 
covered  by  a  thick,  brownish  crust  composed  of  uneven  masses 
piled  one  on  top  of  the  other.  From  beneath  it  exuded  drops 
of  thick  creamy  pus.  Directly  above  this  lesion,  on  the 
dorsum  of  the  hand,  is  a  second  lesion  of  a  rounder  shape  about 
one  and  one-half  inches  by  two  and  a  quarter.  This,  too, 
was  covered  by  a  brownish  crust  of  the  same  formation  which 
characterized  the  greater  number.  This  crust  was  thick,  ele- 
vated above  the  level  of  the  surrounding  skin,  and,  roughly, 
flatly  conical,  the  central  portion  being  higher  than  the  periph- 
eral. It  was  made  up  of  a  series  of  superimposed  layers.  The 
oldest  and  uppermost  layers  had  dried  to  almost  leathery 
hardness  and  had  become  sunken  so  that  in  the  centre  of  the 
crust  there  had  formed  a  cup-shaped  depression  about  the 
size  of  the  end  of  the  thumb.  About  the  edge  of  the  cup  a 
narrow  rim  of  crust  projected  slightly  from  which  the  rest 
sloped  away  gradually  until  it  reached  the  level  of  the  skin. 
A  narrow  zone  of  dusky  red  skin  surrounded  the  whole.  From 
the  edge  of  a  lesion  just  above  two  narrow,  parallel,  brownish 
lines  ran  downward  toward  the  edge  of  the  hand  as  if  a  liquid 
trickling  down  had  lightly  cauterized  the  skin.  (Plate  xiv,  Fig. 
5.)  At  the  junction  of  the  middle  and  upper  thirds  of  the  fore- 
arm was  a  lesion,  about  one  and  a  half  by  two  inches,  similar  to 
the  one  just  described,  but  of  a  darker  brown.  Other  lesions 
were  present  just  below  the  elbow  and  on  the  upper  arm  and 
shoulder.  In  general,  the  shape  and  appearance  of  the  crusts 
suggested  somewhat  a  dark-colored  oyster  shell,  the  wider 
and  more  prominent  end  being  above  and  the  thinner,  nar- 
rower end  below.  The  crusts  all  had  a  characteristic  laminated 
structure  with  a  central  cup-shaped  depression  as  already 
described.  The  color  varied  from  a  light  to  an  almost  blackish 
brown." 

"There  were  also  several  lesions  which  varied  enough  from 
this  type  to  warrant  further  description.  In  addition  to  the 


246  SIXTH  INTERNATIONAL 

lesion  on  the  back  of  the  hand,  those  on  the  outer  side  of  the 
forearm  and  on  the  top  and  front  of  the  shoulder,  and  the  one 
on  the  outer  aspect  of  the  forearm  immediately  below  the 
shoulder,  had  narrow  lines  extending  from  the  lower  edge 
downward,  which  suggested  the  gravitation  of  an  excess  of 
liquid  from  the  main  lesion.  From  the  ulcer  on  the  forearm 
near  the  elbow  there  were  two  of  these  lines,  running  down- 
ward and  outward  over  the  outer  side  of  the  forearm,  which 
varied  in  width  from  an  eighth  to  a  quarter  of  an  inch,  con- 
tracting and  expanding  irregularly  along  their  course.  The 
base  was  dry,  in  shape  concave  or  bulbous  and  of  a  grayish 
white  color.  A  single,  similar  grayish  colored  line  ran  down- 
ward for  a  short  distance  from  the  lesion  just  below  the  tip 
of  the  shoulder  and  another  line  ran  from  the  lesion  on  the 
top  of  the  shoulder.  The  lesion  on  the  front  of  the  shoulder 
was  covered  by  an  almost  black  hemorrhagic  crust.  From 
this  a  channel  ran  downward,  similar  to  those  just  described, 
except  that  its  color  was  very  dark  instead  of  gray.  Im- 
mediately below  this  is  a  patch  which  is  not  ulcerative  like 
the  others,  but  made  up  of  reddish  brown  areas  of  irregular 
and  jagged  shapes  and  sizes,  with  their  long  axes  parallel 
to  that  of  the  arm,  which  look  as  if  they  might  have  been 
caused  by  some  trauma  passing  from  below  upwards  and 
bruising  the  skin  in  its  passage.  The  lesion  on  the  upper  arm 
below  the  shoulder  resembles  the  others  described  in  its  upper 
portion,  but  differs  in  its  lower  portion  in  that  it  becomes  more 
and  more  superficial  as  it  progresses  downwards.  The  crusting 
becomes  less  and  less  marked,  finally  disappearing  and  being 
replaced  by  an  erythema  which  streams  downward  in  lines 
of  darker  and  lighter  shades  to  terminate  in  ragged  projections 
which  are  lost  in  the  healthy  skin.  As  stated,  a  narrow  canal 
runs  farther  down  from  the  lower  edge.  The  radiating, 
irregular,  streaming  effect  suggested  strongly  the  stroke  of 
a  brush  unevenly  applied.  In  several  of  the  lesions  the  brown- 
ish crust  is  surrounded  by  a  narrow  grayish  white  line.  All 
the  lesions  were  said  to  be  sensitive,  but  of  this  there  was  no 
evidence  if  they  were  touched  unawares.  When  the  patient 
realized  they  were  being  handled  they  suddenly  became  very 
tender." 


DERMATOLOGICAL  CONGRESS  247 

"On  the  dorsum  of  the  right  foot  were  three  sharply  defined 
lesions,  one-fourth  inch  in  diameter,  covered  by  black  crusts 
and  surrounded  by  a  narrow  erythematous  zone.  These  were 
of  two  or  three  days'  duration  and  were  the  last  lesions  to 
develop. " 

The  crusts  of  the  various  lesions  were  too  adherent  to  be 
removed  easily,  but  by  means  of  corrosive  sublimate  soaks 
and  poultices  they  were  gradually  softened  and  loosened. 
In  spite  of  their  formidable  appearance  the  process  underlying 
them  was  found  to  be  quite  superficial,  with  bright  red,  easily 
bleeding  granulations  bathed  in  serum.  Healing  progressed 
satisfactorily  under  the  corrosive  dressings  until  one  day 
the  patient  was  discovered  picking  at  a  nearly  healed  lesion 
with  his  finger-nail.  He  had  succeeded  in  tearing  away  nearly 
the  entire  newly-formed  tissue.  On  other  occasions  he  was 
seen  rubbing  the  crusts  about  over  the  ulcer  beneath.  In 
this  manner  he  had  caused  lesions  which  had  become  per- 
fectly dry  to  secrete  profusely.  When  this  secretion  dried 
a  new  layer  had  been  added  to  the  old  crust.  Finally,  on 
April  1 3th,  the  arm  was  enclosed  in  a  sealed  dressing  under  which 
healing  progressed  so  rapidly  that  by  April  3oth,  all  but  three 
of  the  ulcers  were  entirely  healed  and  these  three  were  healing. 
On  the  day  of  his  discharge  the  nurse  left  the  patient  for  a 
short  time  after  removing  the  dressing.  Upon  her  return  she 
found  that  nearly  every  one  of  the  lesions  had  been  converted 
into  superficial  ulcerations.  The  patient  admitted  that  he 
had  rubbed  them. 

On  April  ist,  at  6  P.M.  ,  the  patient  had  an  attack  of  twitching 
of  the  muscles  of  the  face  and  spasmodic  movements  of  the 
arms  and  legs  which  simulated  poisoning  by  strychnine.  The 
spasms,  which  followed  upon  the  slightest  noise,  lasted  for 
but  a  few  seconds  and  gradually  became  less  and  less  frequent. 
The  patient  was  bathed  in  a  profuse  perspiration  and  appeared 
to  be  in  pain,  but  when  asked  about  it  replied  that  he  had 
none.  The  pulse  was  rapid  and  thready.  Knee-jerks  were 
normal.  No  tenderness  of  muscles  anywhere.  After  re- 
ceiving considerable  amounts  of  sedatives  he  became  quiet. 
It  was  reported  that  later  in  the  night  he  vomited  a  considerable 
amount  of  dark  material  which  did  not  seem  to  be  blood.  The 


248  SIXTH  INTERNATIONAL 

next  morning,  the  temperature,  which  had  risen  slightly  in  the 
afternoon  preceding  the  attack,  had  fallen  and  did  not  rise 
again.  Nothing  abnormal  could  be  discovered  on  physical 
examination.  The  patient  complained  that  he  was  unable 
to  turn  over  in  bed,  but  when  given  very  slight  help  he  suc- 
ceeded. He  also  complained  of  a  pain  in  the  spine  between 
the  shoulders  which  prevented  him  from  sitting  up.  Never- 
theless, he  sat  up  in  a  very  short  time.  He  continued  to 
complain  of  pain  between  the  shoulders  for  some  days  after. 
Toward  the  end  of  April  he  complained  of  inability  to  extend 
the  fingers  of  the  right  hand,  and  this  condition  persisted 
up  to  the  time  of  his  discharge. 

Dr.  Waterman,  who  had  made  an  examination  of  the 
nervous  system  shortly  after  the  patient's  admission,  had 
followed  the  case  and  April  27th  reported: 

"When  asked  how  he  had  been  getting  along  during  his 
stay  in  the  hospital,  the  patient  said,  with  apparent  relish: 
'Well,  really,  Doctor,  I  can't  say  that  I  am  one  bit  better 
than  when  I  came  in. '  This,  in  spite  of  the  fact  that  the 
lesions  on  the  arm  had  practically  all  healed.  He  says,  how- 
ever, that  he  is  in  constant  pain,  although  there  are  no  outward 
signs  of  this.  The  senses  of  touch  and  pain  are  almost  absent 
over  the  right  half  of  the  body,  face,  and  extremities,  while 
the  left  half  is  very  sensitive  to  both.  Almost  complete 
hemianopsia.  The  hearing  is  much  diminished  in  the  right 
ear,  a  watch-tick  being  heard  at  four  inches  which  is  heard 
two  feet  away  on  the  left  side.  The  right  cornea  is  insensitive 
to  touch  and  the  mucous  membrane  of  the  right  nostril  is 
insensitive  to  pin-prick.  Knee-jerks  are  equal  and  lively. 
Pupils  equal  and  react  normally. " 

On  May  i6th,  Dr.  Waterman  made  the  following  report: 
"The  motor  disturbance  of  the  right  arm  is  manifested  by 
an  almost  complete  loss  of  strength  for  all  movements  and  the 
fingers  are  held  in  a  state  of  contraction  while  the  arm  is 
flexed  at  the  elbow.  All  movements  can  be  made  to  some 
extent,  and  through  encouragement  the  amount  of  motion  is 
increased.  The  reaction  to  faradism  is  present  in  all  the 
muscles." 

At  no  time  during  the  patient's  stay  in  the  hospital  were 


DERMATOLOGICAL  CONGRESS  249 

we  able  to  reproduce  the  lesions  by  mechanical  trauma. 
Scratches  healed  readily  and  vesicles  produced  by  cantharides 
plaster  healed  without  incident.  A  crust  from  one  of  the 
latest  lesions  was  submitted  to  a  chemical  examination,  but 
the  result  was  negative. 

After  his  discharge  from  the  hospital  (May  i8th)  the  patient 
came  to  the  O.  P.  D.  on  June  2gth.  His  appearance  was  greatly 
improved  and  all  of  the  lesions  had  healed  except  one  area 
about  the  size  of  a  cent  on  the  shoulder  which  was  not  quite 
closed  over.  He  said  that  there  was  some  burning  over  the 
sites  of  the  old  lesions.  Sensation  was  everywhere  normal. 
Reactions  normal. 

SUMMARY.  Male,  40.  Hysteria.  Right-sided  hysterical 
hyperassthesia  and  anaesthesia.  Trauma  of  end  of  right 
forefinger.  First  manifestation  on  site  of  wound.  Long- 
continued  succession  of  lesions  in  crops.  Spread  of  affection 
upward.  First  lesion  round  ulcer.  Supposed  infection  with 
swelling  and  redness  of  back  of  hand  and  forearm,  but  without 
marked  rise  in  temperature.  Ulcer  spread,  involving  bone. 
Amputation  of  terminal  phalanx.  Reinfection.  Am- 
putation at  metacarpo-phalangeal  joint.  New  ulcerative 
lesions  higher  up — superficial,  round,  covered  with  blackish 
crusts.  No  tendency  to  heal.  Pain  in  lesions  radiating  up 
arm  constant  feature.  Intervals  between  outbreaks  varied. 
Stretching  of  median  nerve  of  only  temporary  benefit.  Fol- 
lowed in  three  months  by  eruption  of  different  type  scattered 
over  upper  arm  without  relation  to  nerve  distribution.  Sting- 
ing of  part,  abrupt  appearance  of  black  spot  spreading  laterally. 
Lesions  no  longer  round,  but  oval  or  spindle-shaped,  often 
with  narrow  lines  projecting  downward  from  lowest  portion ; 
some  with  tails,  covered  with  crusts  sunken  in  centre,  leath- 
ery, laminated,  brownish,  greenish,  and  blackish;  serous 
discharge  from  beneath  many;  some  with  narrow,  inflam- 
matory zone  surrounding,  some  without.  Ulcerations  su- 
perficial. Healing  tedious.  Closed  dressing  healed.  Lesions 
re-opened  by  patient  by  rubbing.  No  disease  of  internal 
organs.  No  organic  disease  of  nervous  system.  Duration 
of  affection  about  eighteen  months.  No  caustics  ever  dis- 
covered, but  patient  caught  moving  crusts  over  underlying 


250  SIXTH  INTERNATIONAL 

ulcers.  Admitted  later  that  he  had  broken  open  healed 
lesions. 

These  four  cases  presented  in  common  an  eruption  oc- 
curring in  crops  at  various  intervals  for  long  periods,  appearing 
first  in  the  neighborhood  of  a  preceding  trauma  and  with  a 
tendency  to  upward  spread.  The  eruptions  quickly  became 
gangrenous,  sometimes  with  preceding  erythema  and  vesicles, 
sometimes  without  one  or  both.  Slow  healing  was  char- 
acteristic. In  three  cases  the  eruption  was  limited  to  one 
hand  or  arm,  and  one,  beginning  on  one  arm,  involved  the 
body  later.  The  lesions  usually  appeared  at  night  or  when 
the  patient  was  free  from  observation.  Healing  progressed 
under  closed  dressing  without  other  treatment.  The  patients 
were  never  detected.  Although  two  patients  were  discovered 
rubbing  the  lesions,  it  is  probable  that  by  this  they  merely 
prevented  healing  and  that  the  original  eruption  was  caused 
by  other  means.  The  eruptions  themselves  sometimes 
changed  in  type  in  the  same  patient.  The  inaccessible  parts 
were  exempt  from  attack.  Especially  to  be  noted  was  the 
presence,  or  at  least  the  history,  of  more  or  less  marked 
hysteria.  No  adequate  motive  for  self-mutilation  was  dis- 
covered. Sometimes  the  eruptions  were  preceded  by  sub- 
jective symptoms  of  pain  or  burning.  The  lesions  resembled 
those  of  no  known  disease. 

Continued  study  led  to  the  conviction  that  the  eruptions 
were  continued,  at  least,  by  artificial  means  even  if  not  arti- 
ficially begun.  In  view  of  the  absence  of  the  actual  proof 
of  their  artificial  creation,  two  questions  occurred  to  me  which 
have  led  to  the  following  investigations.  Is  the  hypothesis 
of  artificial  production  without  positive  proof  any  more 
doubtful  than  any  diagnosis,  say  of  pneumonia,  without  an 
autopsy?  Further,  how  do  the  cases  of  so-called  spontaneous 
origin  compare  clinically  with  those  of  known  artificial  origin  ? 
The  analyses  of  the  recorded  cases,  with  a  comparison,  point 
by  point,  of  the  cases  considered  spontaneous  with  the  artifi- 
cially produced,  should  at  least  indicate  a  working  hypothesis. 

I  have  used  for  this  analysis  ninety  cases  of  either  artificial 
or  supposedly  spontaneous  origin  and  have  excluded  from  it 
such  as  were  due  to  bacteria,  arterio-sclerosis,  or  to  an  organic 


DERMATOLOGICAL  CONGRESS  251 

disease  of  the  nervous  system.  These  ninety  cases  have  been 
divided  into  two  groups :  ( i)  the  artificial,  which  includes  those 
cases  produced  by  self -infliction ;  and  (2)  the  spontaneous, 
which  includes  those  supposed  to  be  due  to  internal  causes. 
In  assigning  these  cases  to  one  group  or  the  other  I  have  tried 
in  every  instance  to  follow  the  expressed  or  implied  opinion 
of  the  reporter.  As  a  result  of  this  classification  it  is  found 
that  forty-nine  cases  belong  in  the  spontaneous  group  and 
forty-one  in  the  artificial. 

Sex:  Forty-three  of  the  forty-nine  spontaneous  cases 
occurred  in  females  and  six  in  males.  All  the  artificial  cases 
were  in  females. 

Hysteria:  I  wish  to  lay  especial  emphasis  upon  the  fact 
that  the  analysis  shows  that  practically  every  patient  in  both 
groups  had  suffered  from  some  form  of  hysteria.  In  the 
abbreviated  reports  of  ten  artificial  cases  and  three  spon- 
taneous, no  mention  was  made  of  its  presence  or  absence. 
Of  thirty-one  artificial  cases,  twenty-seven,  or  eighty-seven  per 
cent.,  were  hysterical  and  four  were  said  to  show  no  signs  of 
hysteria.  Of  forty-six  spontaneous  cases,  hysteria  was  present 
in  forty,  or  81.6  per  cent,  and  absent  in  six  cases. 

Age:  The  age  at  which  the  affection  occurred  most  often 
was  the  same  in  both  groups,  for  ninety  per  cent,  of  the 
patients  with  artificial  eruptions  and  eighty-six  per  cent,  of  the 
patients  with  spontaneous  eruptions  were  under  thirty. 

Trauma:  A  history  of  traumatism  preceding  the  first 
manifestation  was  as  frequent  in  the  artificial  cases  as  in  the 
spontaneous,  having  been  obtained  in  forty-four  per  cent,  of 
the  artificial  and  in  forty-five  per  cent,  of  the  spontaneous  cases. 

"Incubation":  Neither  group  showed  a  characteristic 
"incubation  period"  or  interval  between  the  trauma  and  the 
first  appearance  of  the  eruption.  In  both,  there  were  cases 
in  which  the  eruption  followed  the  injury  almost  immediately, 
and  others  in  which  the  first  outbreak  was  delayed  for  days 
or  months  or  even  years. 

Site  of  First  Eruption:  In  the  majority  of  both  artificial 
and  spontaneous  cases  in  which  there  was  preceding  trauma, 
the  first  eruption  made  its  appearance  at  or  near  the  site  of 
the  injury. 


252  SIXTH  INTERNATIONAL 

Onset:  It  was  characteristic  of  both  groups  for  the  eruption 
to  appear  abruptly,  to  progress  to  ulceration  or  gangrene 
with  great  rapidity,  and  then  to  heal  very  slowly. 

Eruption:  It  could  not  be  determined  that  either  group 
possessed  a  characteristic  eruption.  The  commonest  lesions 
in  both  eruptions  were  erythema,  vesicles,  bullae,  ulcers,  and 
gangrene,  which  occurred  in  about  the  same  percentage  of 
cases.  Papules  or  nodules  occurred  more  frequently  in  the 
spontaneous  cases  than  in  the  artificial.  Most  often  the  erup- 
tion began  with  an  erythema  upon  which  vesicles  or  bullag 
quickly  developed,  followed  by  ulceration  or  gangrene.  This 
mode  of  development  was  the  one  most  frequently  seen  in  both 
artificial  and  spontaneous  cases  but  a  great  number  of  varieties 
of  the  type  were  met  quite  often.  It  was  not  unusual  for 
lesions  to  abort  in  either  the  erythematous  or  vesicular  stage. 
Occasionally  gangrene  appeared  without  any  preliminary 
stage  or  perhaps  with  only  one.  It  was  not  uncommon  to  find 
in  one  patient  all  the  various  methods  represented  at  the  same 
time  in  different  lesions.  Further,  there  were  artificial  cases, 
as  well  as  spontaneous,  in  which  the  development  changed 
with  the  different  crops  of  lesions. 

Shape  of  Lesions:  Little  could  be  learned  about  the  shape 
of  lesions,  as  the  reports  were  not  only  scanty  but  were  also 
indefinite,  not  always  stating  whether  the  lesion  described 
was  a  vesicle  or  an  ulcer.  Such  figures  as  I  could  collect 
showed  that  the  lesions  were  round  in  five  artificial  cases 
and  two  spontaneous;  oval  in  four  artificial  and  four  spon- 
taneous; linear  in  twelve  artificial  and  four  spontaneous; 
angular  in  three  artificial  and  eight  spontaneous. 

Inflammatory  Zone:  Singer  is  often  quoted  to  the  effect 
that  "  in  simulated  gangrene  the  surroundings  of  the  ulcerated 
or  gangrenous  area  must  be  irritated.  It  is  not  credible  .  .  . 
that  a  caustic  which  causes  a  rather  deep  destruction  should 
not  disturb  the  immediate  neighborhood  of  the  part  directly 
affected.  Swelling  and  hyperasmia  are  the  most  common 
appearances  in  the  neighborhood  of  artificially  cauterized 
areas. "  This  statement  is  directly  contradicted  by  the 
experiments  of  Gross  and  Narath,  both  of  whom  found  that 
by  varying  the  strength  and  the  duration  of  the  application  they 


DERMATOLOGICAL  CONGRESS  253 

could  reproduce  at  will  any  lesion  from  redness  to  gangrene 
often  without  any  hyperaemia  or  redness  surrounding  and 
without  any  suspicious  irregularities.  In  our  series  only  nine 
artificial  cases  are  stated  to  have  had  an  inflammatory  zone 
about  the  lesions,  while  it  was  present  at  some  time  in 
twenty  spontaneous  cases.  Wheals  or  a  general  swelling  of 
the  part  occurred  only  six  times  in  the  artificial  cases  com- 
pared to  eight  times  in  the  spontaneous. 

Crusts:  No  conclusion  can  be  drawn  from  the  color  of  the 
crusts  as  the  percentage  of  the  occurrence  of  brown,  black, 
gray,  white,  yellow,  or  green  crusts  was  very  nearly  of  the 
same  frequency  in  both  classes.  Some  writers  have  advised 
a  test  of  the  reaction  of  the  crust  as  a  means  of  determining 
whether  a  caustic  has  been  used.  That  the  test  is  not  to  be 
relied  upon  for  the  diagnosis  is  well  illustrated  by  the  ex- 
periences of  Stubenrauch  and  Gross,  each  of  whom  found 
the  crusts  in  his  own  case  alkaline.  But  whereas  this  reaction 
confirmed  Stubenrauch  in  his  opinion  as  to  the  spontaneous 
origin  of  the  eruption  it  was  proved  that  the  eruption  in 
Gross's  case  was  produced  by  hydrochloric  acid. 

Crops:  The  appearance  of  the  eruption  in  crops  at  irregular 
and  varying  intervals  was  equally  common  to  both  groups. 
The  outbreaks  sometimes  followed  close  upon  one  another  and 
sometimes  were  separated  by  varying  intervals  of  longer  or 
shorter  duration.  In  many  instances  a  series  of  crops  in  rapid 
succession  would  be  followed  by  a  long  period  of  freedom  after 
which  would  come  another  period  of  crops  in  rapid  succession. 
In  still  other  cases  each  crop  was  succeeded  by  a  long  free 
interval. 

Site  of  Eruption:  In  about  fifty  per  cent,  of  the  artificial 
and  fifty-seven  per  cent,  of  the  spontaneous  cases  the  erup- 
tion appeared  first  upon  either  a  hand  or  an  arm,  after  which 
each  succeeding  eruption  usually  appeared  higher  up  than  the 
last.  When  the  trunk  was  reached  all  semblance  of  an 
orderly  progression  was  lost  and  the  later  crops  appeared  in 
a  haphazard  fashion  on  any  part  of  the  body.  The  rarity 
of  the  spontaneous  eruption  upon  the  parts  which  were  not 
easily  reached  was  significant  when  considered  in  connection 
with  the  fact  that  the  parts  most  easily  accessible  were 


254  SIXTH  INTERNATIONAL 

also  the  very  regions  most  frequently  attacked  by  the 
artificial  eruptions. 

Frequency  of  Occurrence:  The  analysis  showed  that  the 
eruption  appeared  upon  the  back  twice  in  the  artificial  cases 
and  nine  times  in  the  spontaneous ;  on  the  genitals,  once  in  the 
artificial  and  once  in  the  spontaneous;  on  the  mucous  mem- 
branes, twice  in  the  artificial,  five  times  in  the  spontaneous; 
on  the  face,  thirteen  times,  thirty-one  per  cent.,  in  the  arti- 
ficial, nine  times,  eighteen  per  cent.,  in  the  spontaneous;  on 
the  front  of  the  body,  twenty-four  times,  fifty-nine  per  cent., 
in  the  artificial,  twenty-seven  times,  fifty-five  per  cent., 
in  the  spontaneous  cases.  That  is,  the  eruption  involved 
the  arms,  the  front  of  the  body,  and  the  genitals  with  nearly 
equal  frequency  in  the  cases  of  the  two  groups.  The  face 
was  attacked  more  often  in  the  artificial  than  in  the  spon- 
taneous cases,  and  the  mucous  membranes  and  some  part  of 
the  back  were  attacked  more  often  in  the  spontaneous  cases. 

Limitation  of  Eruption:  As  an  ascending  neuritis  is  often 
given  as  the  cause  of  a  spontaneous  eruption  it  is  rather  sur- 
prising to  find  that  more  artificial  than  spontaneous  eruptions 
were  limited  to  one  part — for  example,  to  an  arm.  Forty-nine 
per  cent,  of  the  artificial  cases  were  limited  to  a  single  part, 
but  only  twenty- two  per  cent,  of  the  spontaneous.  On  the 
body,  however,  the  conditions  were  reversed,  for,  while  of 
thirty-one  spontaneous  cases  which  involved  the  body, 
fifty-two  per  cent,  were  confined  to  one  side,  out  of  twenty- 
nine  artificial  cases  only  forty-one  per  cent,  had  such  a 
unilateral  distribution.  Symmetry  was  not  a  marked  feature 
of  the  bilaterally  distributed  cases  of  either  class. 

Continuance  of  Crops:  It  has  been  claimed  that  the  spon- 
taneous cases  can  be  distinguished  from  the  artificial  by  the 
fact  that  the  spontaneous  eruption  continues  to  appear  beneath 
closed  bandages  and  while  the  patient  is  under  the  strictest 
observation.  The  rule  is  broken  so  often,  however,  by  both 
artificial  and  spontaneous  cases  alike  that  the  claim  has  no 
truth.  The  same  may  be  also  said  of  the  argument  that  the 
failure  to  detect  the  patient  points  to  the  spontaneous  nature 
of  the  eruption,  for  a  number  of  cases,  which  were  eventually 
proved  to  be  of  artificial  origin,  were  not  detected  for  months. 


DERMATOLOGICAL  CONGRESS  255 

In  one  case,  indeed,  it  was  five  years  before  the  true  nature  of 
the  eruption  was  discovered. 

Microscopic  Findings:  The  varied  interpretations  of  the 
microscopic  changes  by  the  advocates  of  the  spontaneous 
theory  proves  that  the  pathological  changes  were  not  char- 
acteristic. One  man  believed  that  his  findings  demonstrated 
the  internal  origin  of  the  eruption,  while  another  said  that 
they  showed  an  infection.  Still  a  third  referred  the  changes 
to  endarteritis  and  thrombosis.  Brandweiner,  who  denies 
the  theory  of  an  artificial  origin,  says  that  the  changes  in  the 
early  stages  are  analogous  to  herpes  zoster  and  that  the  late 
changes  are  indistinguishable  from  those  of  a  burn  or  a  caustic. 
The  differences  found  in  the  changes,  Rona  says,  are  due 
entirely  to  the  use  of  different  caustics  in  different  concen- 
trations, to  variations  in  the  methods  and  duration  of  the 
applications,  and  to  the  varying  irritability  of  the  different 
individuals. 

If  we  now  consider  this  detailed  analysis  and  comparison 
of  the  cases  of  artificial  and  of  spontaneous  origin  as  a  whole, 
the  similarity  of  the  two  groups  is  so  striking  in  every  essential 
that  we  may  draw  the  following  conclusions. 

1.  We  cannot  distinguish  clinically  between  the  cases  of 
known  artificial  origin  and  those  of  unknown  or  so-called 
spontaneous  origin. 

2.  This  clinical  similarity  justifies  us  in  the  belief  that 
the  cases  of  unknown,  i.e.,  spontaneous  origin  are  due  to  the 
same  causes  as  the  cases  of  known  origin.     The  burden  of 
proof  lies  with  those  who  deny  this. 

3.  The  hypothesis   of   an   artificial   production   without 
positive  proof  is  no  more  doubtful  than  any  diagnosis,  say 
of  pneumonia,  without  an  autopsy. 

Up  to  the  present  time  no  single  theory  of  etiology  has 
been  presented  which  can  be  applied  to  all,  or  even  to  the 
majority,  of  the  cases  of  multiple  gangrene.  The  theory  that 
the  eruption  is  caused  by  vaso-motor  or  tropho-neurotic  changes 
is  obviously  incomplete.  Some,  recognizing  its  incompleteness, 
seek  a  remedy  in  a  presupposition  of  some  sort  of  disturbance 
in  the  central  nervous  system.  Other  men  assign  the  cause 
to  an  ascending  neuritis  produced  by  truama  and,  to  explain 


256  SIXTH  INTERNATIONAL 

the  outbreaks  on  distant  parts,  assume  that  the  neuritis, 
having  reached  the  cord,  involves  other  segments  and  thence 
spreads  to  other  nerve  trunks.  This  is,  of  course,  merely 
an  unproved  theory.  In  the  absence  of  atrophy  and  other 
signs  which  usually  accompany  a  long-continued  injury  to 
the  nerve,  the  assumption  of  an  ascending  neuritis  is  not  justi- 
fied even  in  such  cases  as  are  limited  to  a  single  part.  Further, 
there  are  men  who  are  reluctant  to  admit  that  any  human 
being  would  voluntarily  submit  to  such  pain  and  disfigurement, 
and  apparently  base  their  conviction  of  the  spontaneous  origin 
of  the  eruption  upon  their  failure  to  find  the  motive  or  the 
means  of  artificial  production.  Such  divergent  views  must 
necessarily  lead  to  much  discussion.  Somewhere  there  must 
be  a  line  of  evidence  leading  to  the  truth.  When  we  examine 
the  comparative  clinical  analysis  previously  referred  to  we 
find  one  invariable  symptom,  i.e.,  hysteria,  the  significance 
of  which  is  receiving  greater  appreciation  just  now  than  ever 
before.  If  we  follow  closely  the  more  recent  investigations 
of  the  neurologists  into  the  nature  of  hysteria,  we  shall  find 
a  theory  so  complete  as  to  explain  all  the  previously  discovered 
half-truths. 

It  is  of  great  importance  that  we  should  realize  that 
hysteria  is  no  longer  considered  as  a  physiological  condition. 
Professor  Janet  says  that  "the  psychological  conception  of 
hysteria  has  the  mastery  to-day  over  the  physiological  con- 
ception. "  Therefore  we  cannot  accept  an  explanation  of  the 
occurrence  of  multiple  gangrene  of  the  skin  which  is  based 
upon  the  physiological  conception  of  hysteria.  The  analysis 
has  already  shown  us  the  almost  universal  occurrence  of 
hysteria  in  connection  with  multiple  gangrene  of  the  skin. 
We  know  also  that  the  two  great  symptoms  of  hysteria  are 
somnambulism  and  suggestion.  If,  therefore,  we  accept  the 
psychological  conception  of  hysteria,  a  complete  and  rational 
theory  of  multiple  gangrene  would  be  that  the  patient,  while 
in  the  psychological  condition  known  as  somnambulism,  has 
produced  the  eruption  by  artificial  means  in  response  to 
suggestion.  Only  such  a  theory  as  this  can  explain  the  limita- 
tion of  these  cases  to  hysterical  patients.  It  reconciles  the 
apparently  divergent  theories  and  explains  the  similarity 


DERMATOLOGICAL  CONGRESS  257 

of  the  eruptions  in  cases  of  unknown  origin  to  those  of  known 
artificial  origin.  Further,  it  does  away  with  all  need  for  a 
motive  and  with  the  incredulity  which  cannot  believe  self- 
mutilation  possible. 

A  brief  study  of  somnambulism  and  suggestion  will  demon- 
strate the  truth  of  these  statements.  Somnambulism  may 
be  defined  as  that  hysterical  state  in  which  an  idea  or  a  feeling 
takes  on  an  exaggerated  growth  which  the  patient  is  powerless 
to  check.  Because  of  this  unchecked  growth,  outside  the 
control  of  the  will,  that  one  idea  acquires  such  importance 
that  it  finally  completely  dominates  the  patient.  This  is 
known  as  somnambulism.  During  this  period  of  the  som- 
nambulistic state  all  functions  are  suppressed  except  those 
directly  concerned  in  the  dominating  idea.  Although  the 
other  functions  still  exist,  they  are  beyond  the  control  of  the 
patient's  will.  The  dominating  idea  disassociates  itself  from 
them  and  develops  outside  the  patient's  consciousness  and 
control.  As  Professor  Janet  expresses  it,  there  is  a  retraction 
of  the  field  of  consciousness.  The  idea,  which  in  this  state 
of  somnambulism  assumes  such  exaggerated  growth,  may 
arise  from  suggestion  from  without  or  from  within.  After  a 
time,  the  somnambulistic  state  disappears,  gradually  or 
abruptly,  but  the  patient  has  no  memory  of  the  somnam- 
bulistic period  and  often  cannot  remember  the  idea  which 
recently  dominated  his  whole  personality.  It  is  also  charac- 
teristic of  hysteria  that,  in  the  same  way  in  which  an  idea 
takes  on  an  exaggerated  growth,  there  may  develop  beyond 
the  patient's  control  various  sensory  disturbances  such  as 
anaesthesia,  hyperaesthesia,  paralysis,  etc. 

These  major  symptoms  of  hysteria  may  also  be  accom- 
panied by  such  minor  symptoms  as  a  lack  of  feeling  and  of 
will,  with  depression  and  a  lowering  of  the  mental  level. 
"The  localization  of  the  hysterical  accidents  on  one  place  or 
another,  or  in  one  function  or  another,  may  be  caused  (i)  by 
suggestion  from  without,  (2)  by  a  process  akin  to  suggestion, 
but  which  is  not  identical  with  it  according  to  the  laws  of 
psychological  automatism,  i.e.,  individuals  who,  having  had 
an  accident  in  certain  circumstances  and  having  been  cured, 
always  recommence  the  same  accident  each  time  they  ex- 

VOL.    I. — 17 


2S8  SIXTH  INTERNATIONAL 

perience  an  emotion,  though  it  has  no  relation  with  the  first" 
(Janet). 

We  have  already  emphasized  the  fact  that  the  cases  of 
multiple  gangrene  of  the  skin  usually  occur  in  hysterical 
patients.  If,  therefore,  we  view  their  skin  affection  in  the 
light  of  this  brief  resume"  of  the  chief  symptoms  of  hysteria, 
their  etiology  is  clear  and  simple.  The  process  may  be  sum- 
marized in  this  way.  A  hysterical  young  woman,  at  some 
time  or  other,  either  wounds  herself  or  sees  a  wound  in  another 
person.  After  an  interval  which  may  be  long  or  short  she 
enters  into  the  somnambulistic  state.  The  wound  acts  as  a 
suggestion  to  her.  In  her  somnambulistic  condition  she  is 
powerless  to  prevent  that  suggestion  of  a  wound  from  attaining 
an  exaggerated  importance.  It  continues  to  develop  until 
it  dominates  her  whole  personality.  She  is  entirely  unable 
to  control  either  the  idea  or  its  power  of  disassociation.  Con- 
trol of  the  sensory  functions  is  lost  and  anaesthesia  follows. 
Finally,  she  yields  to  the  suggestion  of  the  wound  and  produces 
a  similar  lesion  by  any  means  at  hand.  She  suffers  no  dis- 
comfort, as  in  addition  to  the  somnambulism  the  part 
wounded  is  anaesthetic.  She  then  gradually  emerges  from 
the  somnambulistic  state  and  views  the  wound  with  as- 
tonishment. As  she  has  no  memory  of  the  somnambulistic 
period  or  of  the  production  of  the  wound,  she  honestly 
believes  that  the  wound  came  of  itself.  Thereafter,  so  long 
as  the  condition  of  hysteria  remains,  any  suggestion,  even 
if  remote,  will  reproduce  the  same  conditions  and  a  fresh 
lesion  is  made.  The  recurrences  cease  only  with  the  cure  of 
hysteria. 

If  this  theory  is  correct  the  initial  suggestion  may  arise 
from  a  wound,  or  a  tropho-neurotic  process,  or  a  neuritis,  or 
from  any  other  cause.  The  succeeding  eruptions,  however, 
are  not  the  result  of  the  initial  process  nor  of  the  hysteria 
itself,  but  of  an  unconscious  yielding  to  an  idea  of  exaggerated 
growth  which  forces  the  patient  to  self -mutilation,  outside 
her  memory  and  her  will. 

In  conclusion,  let  me  again  quote  from  Professor  Janet: 
"  It  is,  perhaps,  not  very  serious  not  to  recognize  an  hysterical 
accident  and  not  to  treat  it,  but  what  is  always  very  serious 


PLATE  XIII— To  Illustrate  Dr.  Harvey  P.  Towle's  Article. 


FIG.  1. 


FIG.  2. 


FIG.  3. 


PLATE  XIV— To  Illustrate  Dr.  Harvey  P.  Towle's  Article. 


FIG.  4. 


\ 


FIG.  5. 


DERMATOLOGICAL  CONGRESS  259 

is  to  mistake  an  hysterical  accident  for  another  one  and  to 
treat  it  for  what  it  is  not. " 

Finally,  I  wish  to  express  my  thanks  to  the  Staff  of  the 
Dermatological  Department  for  their  aid  and  encouragement, 
and  to  the  Staffs  of  the  Surgical  and  Nerve  Departments 
for  their  assistance  in  the  completion  of  the  case  records,  and 
finally  to  the  physicians  who  cleared  up  many  obscure  points 
in  the  patient's  history  by  their  letters. 

Discussion 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  that  while  he 
fully  believed  that  all  of  these  cases  were  self-inflicted,  very  able 
men  who  had  had  such  cases  under  observation  for  long  periods  of 
time  had  expressed  the  belief  that  the  lesions  were  not  self-pro- 
duced, although  they  were  perfectly  aware  of  such  a  possibility 
and  even  probability. 

PROF.  E.  GAUCHER,  of  Paris,  said  he  had  listened  to  Dr.  Towle's 
paper  with  much  pleasure,  because  not  very  long  ago  he  was  the 
only  one,  with  Prof.  Raymond,  to  defend  the  existence  of  gangraena 
hysterica.  This  condition,  he  thought,  must  not  be  stricken  from 
our  nosology.  Of  course,  the  gangrene  was  a  secondary  phe- 
nomenon, caused  by  infection  of  a  slight  abrasion  of  the  cuticle,  but 
hysteria  prepared  the  ground  on  which  the  gangrene  developed. 
In  a  healthy  person,  such  a  dermic  lesion  would  never  be  followed 
by  gangrene,  but  when  hysteria  had  produced  ischaemia,  then  it 
might  develop.  Despite  the  necessity  of  an  initial  lesion,  hysteria 
was  absolutely  an  essential  factor.  This  was  enough  to  justify 
the  maintenance  of  gangraena  hysterica  as  a  separate  morbid 
entity. 

Adjournment  at  i  p.  m 


AFTERNOON  SESSION  3  P.M. 

DR.  FRANCIS  J.  SHEPHERD  of  Montreal,  Vice-President, 
in  the  Chair. 

THEME  I.— THE  ETIOLOGICAL  RELATIONSHIP 
OF  ORGANISMS  FOUND  IN  THE  SKIN  IN 
EXANTHEMATA 

PRESENTED  BY  PROF.  W.  T.  COUNCILMAN  AND  PROF.  GARY 
N.  CALKINS 

ON  THE  RELATION  OF  THE  BODIES  FOUND 
IN  THE  SKIN  LESION  OF  VARIOLA  AND 
SCARLET  FEVER  TO  THE  ETIOLOGY  OF 
THESE  DISEASES 

(WITH    LANTERN-SLIDE   DEMONSTRATIONS) 

BY  PROF.  W.  T.  COUNCILMAN,  OF  BOSTON 

In  the  last  three  decades  there  has  been  greater  advance 
made  in  knowledge  of  disease  than  in  any  previous  century. 
In  this  period  the  general  nature  of  the  infectious  diseases 
has  been  made  clear;  the  etiology,  the  mode  of  infection, 
the  prevention,  and  treatment  of  several  of  these  diseases 
have  been  definitely  established.  New  methods  of  work  have 
been  found;  more  and  better  material  has  been  provided  for 
observation  and  experiment,  and  the  large  number  of  workers 
in  all  parts  of  the  world  has  enabled  means  and  methods  to  be 
freely  utilized.  In  no  domain  of  science  has  the  value  of  the 
experimental  method  been  more  fully  demonstrated  than 
in  medicine  for  we  find  that  our  knowledge  of  disease  stands 
in  direct  ratio  to  the  possibility  of  investigation  by  the 
experimental  method. 

260 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS         261 

While  the  knowledge  of  the  infectious  diseases  has  so 
greatly  increased  during  the  period  mentioned,  the  advance 
in  knowledge  of  the  three  exanthemata — small-pox,  scarlet 
fever,  and  measles — has  been  but  slight.  There  seem  to  be  a 
number  of  reasons  for  this.  The  diseases  in  question  are  not 
at  all,  or  to  but  a  limited  extent,  open  to  the  experimental 
method  of  investigation.  They  occur  to  a  greater  extent  in 
epidemics  and  are  taken  care  of  in  special  hospitals  in  which 
investigation  does  not  hold  so  high  a  place  as  in  the  more 
general  hospitals,  and  finally  the  analogy  with  the  other 
infectious  diseases  is  incomplete. 

Certain  members  of  the  pathological  department  of  Har- 
vard University  undertook  an  investigation  of  small-pox 
during  the  small  epidemic  of  the  disease  which  appeared  in 
Boston  in  1901  and  1902.  Full  opportunity  for  investigation 
by  autopsies  and  by  hospital  residence  was  given  by  the 
municipal  authorities.  The  results  of  the  investigation  were 
published  in  1904.  Drs.  Brinckerhoff  and  Tyzzer  subse- 
quently went  to  Manila  and  undertook  an  experimental 
investigation  of  the  disease  in  monkeys.  Every  facility  for 
this  investigation  was  afforded  by  the  health  authorities 
of  the  islands.  In  the  time  at  my  disposal  it  will  be  possible 
only  to  state  in  the  most  general  way  the  results  which  we 
have  obtained.  The  details  of  the  work  were  published  in  the 
Journal  of  Medical  Research  in  1904  and  1906. 

In  the  specific  lesions  of  the  skin  and  mucous  membrane  in 
small-pox  certain  bodies  are  found  which  vary  in  form,  struc- 
ture, and  size.  They  are  found  in  the  very  earliest  lesions 
and  increase  in  number  up  to  the  full  development  of  the 
pustule.  They  occur  within  the  epithelial  cells,  within  the 
nuclei,  and  free.  The  forms  within  the  nuclei  are  subsequent 
to  those  which  occur  within  the  cytoplasm.  They  are  present 
in  the  greatest  numbers  in  cases  of  the  greatest  severity  and 
rapidity  of  course.  Their  presence  marks  the  earliest  lesions, 
and  they  are  found  included  in  cells  otherwise  normal.  They 
do  not  occur  as  isolated  structures  but  one  form  follows 
another  by  gradual  transitions  forming  a  cycle  which  corre- 
sponds with  the  cycle  of  development  of  living  things.  In 
the  different  cases  the  same  forms  are  found  at  the  same  period 


262  SIXTH  INTERNATIONAL 

of  the  disease.  The  bodies  increase  rapidly  in  the  lesions 
and  the  lesion  seems  to  increase  in  extent  by  continuous 
infection  of  adjoining  epithelial  cells.  The  forms  which 
occur  within  the  nuclei  differ  strikingly  from  those  which 
occur  within  the  cytoplasm.  We  have  not  hesitated  to 
regard  these  bodies  as  parasites  and  as  the  etiological  factor 
in  the  disease.  The  two  propositions  go  together,  for  they 
are  found  in  no  other  disease  and  precede  those  changes  in  the 
cells  and  tissues  which  constitute  the  lesions.  In  no  disease 
can  the  relationship  between  the  parasite  and  the  lesion  be 
more  definitely  shown. 

In  the  course  of  the  investigation  of  small-pox  a  more 
detailed  study  of  vaccinia  was  undertaken  by  Dr.  Tyzzer. 
In  this  disease  organisms  corresponding  to  those  found  in  the 
cytoplasm  of  the  epithelial  cells  in  small-pox  are  always 
present,  and  in  the  same  definite  relation  to  the  lesions.  They 
can  be  much  better  studied  in  vaccinia,  for  the  material  is 
experimental  and  not  only  can  stages  be  more  easily  pro- 
cured but  better  preservation  of  material  is  possible.  The 
inoculations  can  be  made  in  the  cornea,  and  in  no  other  tissue 
can  such  perfect  cell  studies  be  made.  Dr.  Tyzzer  has  found 
that  the  organism  appears  in  the  epithelial  cells  without  any 
change  either  in  nucleus  or  protoplasm.  First  as  a  small  body 
not  more  than  a  mikron  in  diameter,  rather  dense  and  re- 
fractive, showing  no  structure  and  without  definite  staining 
reaction.  Briefly  stated,  the  bodies  increase  in  size;  nuclear 
material  becomes  differentiated  in  them  and  finally  segmen- 
tation occurs,  the  body  breaking  up  into  a  number  of  bodies 
of  the  same  character  as  those  originally  present.  That  these 
bodies  and  the  structural  change  in  them  are  not  due  to  the 
action  of  hardening  agents  is  shown  by  ultra-violet  photo- 
graphs of  the  living  cells  containing  them.  By  these  photo- 
graphs all  the  details  of  structure  are  more  evident  than  after 
hardening  and  staining.  In  the  hardened  specimens  the  bodies 
seem  to  lie  in  a  vacuole  in  the  cell  which  is  probably  due  to 
contraction  produced  by  fixatives,  for  in  the  ultra-violet 
photograph  no  such  vacuole  is  apparent. 

If  material  from  a  small-pox  lesion  in  man  be  inoculated 
on  an  epithelial  surface  of  a  calf  or  rabbit,  a  lesion  which 


DERMATOLOGICAL  CONGRESS  263 

anatomically  resembles  the  parent  lesion,  the  pock,  is  produced. 
Its  appearance  is  accompanied  by  swelling  of  the  nearest  lymph 
nodes,  fever,  and  constitutional  disturbance.  After  the  process 
has  subsided  there  is  immunity  to  further  inoculation.  The 
material  from  the  lesion  transferred  to  another  calf  produces 
a  similar  result,  and  after  a  series  of  transfers  from  animal  to 
animal  may  be  returned  to  man  and  it  develops,  not  the 
original  disease  small-pox,  but  the  incomparably  milder  disease 
vaccinia.  Many  of  the  strains  of  vaccine  virus  now  used  are 
known  to  have  been  derived  from  small-pox  and  probably 
all  strains  were  originally  so  derived.  Vaccinia  differs  from 
small-pox  in  three  striking  respects: 

1.  The  period  of  incubation  is  shorter,  being  in  man  five 
days.     The  incubation  period  of  small-pox  is  twelve  days. 

2.  In  vaccinia  there  is  no  general  exanthema.     There  may 
be  a  few  vesicles  around  the  site  of  inoculation  but  they  de- 
velop simultaneously  with  and  not  after  the  main  lesion  and 
are  probably  due  to  local  distribution  of  the  virus. 

3.  For  the  development  of  vaccinia  it  is  necessary  that 
the  virus  reach  a  susceptible  epithelial  surface.     It  may  be 
placed  on  such  a  surface  or  be  carried  there  by  the  blood  after 
having  been  injected  into  the  circulation.     The  disease  may 
be  transmitted  from  individual  to  individual  by  immediate 
or  intermediate  contact.     But  the  infection  is  close,  there  is 
no  evidence  of  infection  at  a  distance,  no  evidence  of  such 
extension  of  the  infection  as  is  shown  in  small-pox. 

Vaccinia  agrees  with  small-pox  in  the  similarity  of  the 
lesion  produced  by  inoculation  to  the  pock  and  in  the  fact 
that  both  diseases  may  be  produced  by  the  virus  of  variola. 

If  material  from  a  small-pox  lesion  be  placed  in  contact 
with  a  susceptible  epithelial  surface  of  man  or  of  the  monkey, 
there  develops  at  the  site  of  inoculation  a  lesion  larger  but 
having  the  general  characteristics  of  the  pock,  together  with 
constitutional  disturbances  and  an  exanthem  less  abundant 
but  otherwise  similar  to  the  exanthem  of  small-pox ;  immunity 
to  both  vaccinia  and  small-pox  follows  the  disease.  Inocula- 
tion of  man  with  small-pox  to  produce  immunity  is  no  longer 
practised  in  civilized  lands  and  all  that  we  know  of  the  disease 
in  man  is  from  the  older  literature.  The  disease  differs  from 


\ 

264  SIXTH  INTERNATIONAL 

variola  vera  in  its  milder  course  and  shorter  period  of  incuba- 
tion which  is  eight  instead  of  twelve  days.  There  seems  to 
be  no  qualitative  difference  in  the  virus  of  variola  inoculata  as 
compared  with  variola  vera;  from  the  mild  variola  inoculata 
the  true  disease  is  produced,  infection  taking  place  as  in  variola 
vera.  The  disease  which  is  produced  in  monkeys  corresponds 
rather  with  variola  inoculata  than  with  variola  vera.  Drs. 
Brinckerhoff  and  Tyzzer  failed  in  every  attempt  to  produce 
infection  of  monkeys  otherwise  than  by  inoculation.  The 
inoculation  carried  from  animal  to  animal  produces  the  same 
disease  with  the  exanthem  and  the  same  period  of  incubation. 

I  have  said  that  in  the  lesions  produced  by  inoculation  of 
the  small-pox  in  the  calf  and  rabbit  the  parasites  in  the  cyto- 
plasm of  the  cells  were  found  and  only  there.  In  the  true 
small-pox  produced  in  the  monkey  by  inoculation,  in  addition 
to  the  cytoplasmic  inclusions  the  nuclear  forms  of  the  parasite 
are  found  also.  The  presence  of  these  nuclear  changes  is  the 
sharp  histological  criterion  separating  vaccinia  from  small- 
pox. The  nuclear  inclusions  begin  with  the  appearance  of 
one  or  several  small  circular  masses  in  the  nucleus.  They 
increase  in  size  and  with  growth  show  a  greater  complexity 
of  structure.  The  form  varies;  at  times  the  entire  structure 
appears  to  be  composed  of  a  number  of  small  circles,  in  the 
centre  or  at  the  side  of  which  small  stainable  points  can  be 
made  out.  In  other  cases  there  is  a  large  central  space  around 
which  are  grouped  a  great  number  of  small  spaces  all  bearing 
a  central  dot.  The  nucleus  enclosing  these  bodies  enlarges, 
the  central  chromatin  disappears  leaving  only  a  faint  nuclear 
rim  which  finally  disappears;  the  enclosed  bodies  are  set  free 
and  they  may  be  found  in  the  central  mass  of  broken  down 
cells  mixed  with  exudation.  In  the  degenerated  nuclei  there 
are  often  found  small,  refractive,  brightly  staining  points 
less  than  0.5  /*.  in  diameter. 

We  have  advanced  a  working  hypothesis  as  an  explanation 
of  the  striking  similarity  and  dissimilarity  between  small-pox 
and  vaccinia,  and  since  the  appearance  of  our  work  we 
have  seen  no  reason  to  reject  or  modify  it.  The  organism 
found  in  small-pox  has  two  distinct  cycles  of  development. 
One  cycle  is  passed  within  the  cytoplasm  of  the  epithelial  cells. 


DERMATOLOGICAL  CONGRESS  265 

It  is  only  possible  for  this  cycle  to  develop  in  the  calf  or  rabbit 
and  when  established  in  these  animals  it  remains  fixed  and 
constitutes  the  disease  vaccinia.  The  terminal  agent  in  this 
cycle  of  development  is  only  capable  of  infection  by  close 
contact;  it  is  never  air  borne. 

In  small-pox,  on  the  other  hand,  in  man  and  in  the  in- 
oculated disease  in  the  monkey  there  is  a  complete  development, 
and  the  terminal  infectious  agent  is  more  infectious  and 
infection  extends  over  a  wider  area. 

Professor  Calkins  has  been  associated  with  us  in  our  work 
and  we  have  been  greatly  assisted  by  his  technical  skill  and 
by  the  interpretations  which  his  especial  knowledge  of  the 
protozoa  have  enabled  him  to  make. 

During  the  course  of  the  investigation  of  small-pox,  Dr. 
Mallory  undertook  the  study  of  the  skin  lesions  of  scarlet 
fever  with  the  idea  that  bodies  of  a  similar  nature  to  those 
seen  in  small-pox  and  vaccinia  might  be  present  there.  He 
found  certain  specific  bodies  in  and  between  the  epithelial 
cells  which  he  regarded  as  protozoa  and  the  etiological  factor 
in  the  disease.  The  bodies  differ  in  structure  and  in  staining 
from  those  found  in  small-pox  and  vaccinia  and  in  some  of 
their  phases  of  development  have  some  similarity  to  the 
Negri  bodies  in  rabies.  Dr.  Mallory  describes  them  as 
follows : 

The  bodies  usually  vary  from  2-7  p..  in  diameter  but  occa- 
sionally measure  10-12  //,.  They  may  be  divided  into  two 
sorts,  the  granular  and  the  radiate.  The  granular  bodies 
are  usually  finely  but  occasionally  coarsely  meshed  and 
show  all  variations  in  size  between  the  limits  given.  They 
often  contain  one  or  more  small  but  distinct  vacuoles.  They 
vary  in  shape  from  round  to  elongated  and  lobulated  forms 
suggesting  amoeboid  motion.  The  radiate  bodies  vary  in  diam- 
eter from  4-6  p.  and  are  almost  invariably  radiate  in  shape. 
They  contain  a  central  round  body,  around  which  are  grouped 
on  optical  section  10-18  narrow  segments  which  in  some  cases 
are  united  but  in  others  are  sharply  separated  laterally  from 
each  other.  Occasionally  some  of  the  segments  are  larger 
than  the  others  and  in  their  staining  reaction  and  form  closely 
resemble  the  smallest  granular  bodies.  Sometimes  all  the  seg- 


266         SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

ments  are  seen  as  small  free  bodies  which  still  surround  the 
central  body  or  seem  as  though  they  had  been  fixed  while 
moving  away  from  it  between  the  cells. 

These  two  kinds  of  bodies  are  found  in  three  situations : 

Lying  in  vacuoles  in  the  epithelial  cells  of  the  epidermis, 
to  a  less  extent  between  these  cells,  and  free  in  the  lymph 
vessels  and  spaces  of  the  corium  just  beneath  the  epidermis. 
When  within  the  epithelial  cells  they  usually  cause  indentation 
of  the  nucleus.  The  bodies  are  not  distributed  evenly  but 
usually  occur  in  clumps ;  moreover  the  skin  from  one  location 
may  show  them  chiefly  in  the  lymph  spaces  of  the  corium 
especially  in  the  papillae,  while  in  that  from  another  situation 
they  may  be  almost  entirely  between  or  in  epithelial  cells. 
They  are  always  least  numerous  where  epithelial  cells  are 
most  abundant. 

At  the  time  of  the  first  description  of  these  bodies  they  had 
been  found  in  the  skin  taken  from  over  the  chest  and  abdomen. 
Duval  found  them  in  five  acute  cases  at  autopsy.  Led  by 
their  presence  in  the  lymph  vessels  and  between  the  epithelial 
cells  of  the  epidermis  to  the  belief  that  the  bodies  might  be 
drawn  out  with  the  serum  he  devised  a  simple  method  of  pro- 
ducing rapid  vesication  and  was  able  to  obtain  the  bodies 
often  in  large  numbers  from  vesicles  produced  in  the  groin 
in  five  out  of  eighteen  cases.  The  serum  was  practically  free 
from  cells,  and  the  bodies  could  be  stained  in  cover-slip  pre- 
parations. Duval's  description  of  the  bodies  and  the  method 
of  investigation  will  be  found  in  Virchow's  Arch.,  1905,  vol.  169. 

Time  will  not  allow  me  to  enter  into  the  controversy  as 
to  the  nature  of  these  bodies.  Since  the  publication  of  the 
work  both  on  small-pox,  vaccinia,  and  scarlet  fever  there  has 
been  criticism,  hasty  judgment,  and  but  little  investigation. 
Some  work  has  been  done  in  which  undoubted  products  of 
degeneration  or  artefacts  resulting  from  bad  methods  have 
been  shown  not  to  be  living  parasites.  But  we  have  been 
perfectly  familiar  with  degeneration  products  and  artefacts 
but  have  not  considered  them  because  they  have  no  relation 
to  the  bodies  which  we  describe.  We  are  perfectly  willing 
to  disregard  the  criticism  and  hasty  judgment  and  await 
the  period  of  investigation. 


CYTORYCTES    VARIOLA;    THE    ORGANISM    OF 

SMALL-POX 

(WITH  LANTERN  SLIDE  DEMONSTRATION) 

BY  PROP.  GARY  N.  CALKINS,  OF  NEW  YORK 

One  of  the  chief  arguments  against  the  parasitic  nature 
of  the  cell  inclusions  in  small-pox  tissue  is  the  fact  that  no 
structure  of  cellular  character  can  be  made  out.  Misled  by 
the  usual  expectation  of  finding  a  well-defined  nucleus  and 
cytoplasm,  most  investigators  have  been  unable  to  interpret 
these  inclusions  as  organisms  and  have  taken  the  ground  that 
the  bodies  are  degeneration  phenomena  of  a  unique  type. 

It  is  possible,  of  course,  that  such  observers  are  right,  but 
there  is  also  a  possibility  that  they  have  not  exhausted  all  of 
the  phases  which  cells  and  nuclei,  especially  in  the  group  of 
protozoa,  may  show,  and  it  is  my  privilege  to  point  out  in  the 
few  minutes  at  my  disposal,  some  of  the  features  in  protozoa 
upon  which  is  based  the  contention  that  the  famous  Guarnieri 
bodies  conform  in  structure  and  development  to  a  well- 
defined  protozoon  type. 

In  the  first  place,  there  are  organisms  among  the  protozoa 
in  which  no  formed  nucleus  is  present.  Even  in  the  highest 
types  of  protozoa,  the  infusoria,  there  are  species  in  which 
the  nucleus  is  never  more  than  a  collection  of  granules  (Di- 
leptus  sp.  for  example).  In  the  lowest  organisms  standing 
at  the  opposite  end  of  the  line  of  single-celled  creatures,  the 
bacteria,  there  is  likewise  no  formed  nucleus,  the  place  of 
this  important  organ  of  the  cell  being  taken  by  the  distri- 
buted granules  of  chromatin,  which  in  protozoa,  we  call  the 
chromidium. 

In  the  second  place,  the  protozoa  are  characterized  by  a 
more  or  less  extensive  phase  of  the  life  cycle  in  which  the 

267 


268  SIXTH  INTERNATIONAL 

formed  nucleus  is  replaced  by  such  granules  of  chromatin, 
or  the  chromidium,  the  chromatin  arising  by  secretion  or 
disintegration  of  the  nucleus.  It  is  to  this  phenomenon  in 
particular  that  I  wish  to  call  your  attention,  the  various 
phases  in  the  life  history  of  the  small-pox  organism  being 
interpreted  through  it. 

In  the  group  of  protozoa  known  as  the  rhizopods  the 
chromidium  does  not  exist  at  all  times,  but,  in  the  majority 
of  cases,  is  formed  only  at  periods  preceding  sexual  reproduc- 
tion. This  is  the  case,  for  example,  in  the  great  division  of 
the  foraminifera,  where  in  forms  like  Polystomella,  the  nuclei 
first  divide  a  number  of  times,  giving  rise  to  multi-nucleated 
cells.  The  nuclei  then  break  down  and  disappear  as  formed 
elements,  the  chromatin  being  distributed  throughout  the 
cell  in  granular  form,  thus  giving  rise  to  the  chromidium  by 
fragmentation.  In  Arcella  and  other  fresh-water  rhizopods, 
on  the  other  hand,  the  chromidium  granules  exude  through 
the  membrane  of  the  vegetative  nucleus  until  a  mass  of  ir- 
regular chromatin  material  lies  free  in  the  cell,  while  the 
vegetative  nucleus  retains  its  original  form.  This  latter  type 
of  the  chromidium  is  found  among  the  parasitic  amcebse  in 
forms  like  Chlamydophrys  stercorea,  Entamoeba,  etc.,  and 
is  particularly  characteristic  of  the  rhizopods. 

In  all  cases,  the  chromidium  is  the  most  important  material 
of  the  protozoon  cell,  for  from  its  substance  the  minute  nuclei 
of  the  conjugating  gametes  are  formed.  It  may  be  called  the 
sexual  chromatin,  while  the  formed  vegetative  nucleus  in 
every  case  degenerates  and  disappears,  playing  no  part  what- 
soever in  reproduction,  at  least  of  sexual  reproduction.  If 
no  formed  nucleus  is  present  in  the  cell,  therefore,  we  should 
expect  the  chromidium  at  least  to  be  present. 

This  is  precisely  the  case  in  the  questionable  organisms 
with  which  we  are  dealing.  It  is  also  the  case  in  the  bacteria 
and  in  some  of  the  lower  flagellated  protozoa. 

An  important  and  illuminating  side  light  on  Cytoryctes 
variolae  is  shed  by  the  facts  of  Neuroryctes  hydrophobiae,  the 
cause  of  rabies.  The  greater  part  of  the  life  history  of  this 
organism  is  characterized  by  the  absence  of  a  formed  nucleus, 
which  appears  only  in  the  young  stages  as  a  small  group  of 


DERMATOLOGICAL  CONGRESS  269 

chromatin  granules.  As  the  young  organism  grows,  however, 
the  granules  increase  in  number  and  spread  throughout  the 
cell,  the  original  nucleus  being  recognizable  for  a  considerable 
period. 

The  granules  of  Neuroryctes  are  difficult  to  stain,  possibly 
owing  to  the  mode  of  life  of  the  parasite  in  the  nerve  cells, 
and  the  first  observations  that  were  made  on  it  led  to  the 
belief  that  it,  like  Cytoryctes,  is  a  structure  without  any  of 
the  structural  characteristics  of  a  living  thing.  The  ordinary 
method  that  was  first  used,  showed  it  as  a  highly  vesiculated 
body  in  which  no  nucleus  or  other  part  could  be  differentiated, 
and,  as  the  Negri  body,  its  organized  nature  was  discredited. 
Subsequent  research  by  Negri  and  his  collaborators  in  Italy, 
and  the  splendid  work  of  Dr.  Williams  in  this  country,  have 
established  the  protozoon  nature  of  the  Negri  bodies  beyond 
any  question.  The  latter,  using  a  smear  method,  was  able 
to  fix  and  stain  the  organisms  perfectly,  and  the  vesicles 
which  appeared  in  the  earlier  preparations,  now  appeared  in 
her  preparations  as  chromatin  granules.  She  was  able  to 
show  that  the  organisms  reproduce  by  budding  and  by  division ; 
the  process  taking  place  in  essentially  the  same  way  as  in 
Entamoeba  histolytica,  according  to  Schaudinn's  interpreta- 
tion. In  Entamceba,  the  chromidium  is  formed  prior  to  the 
budding  process,  and  the  buds  are  formed  as  small  buttons 
on  the  periphery  of  the  cell,  each  receiving,  not  a  nucleus, 
but  granules  of  chromatin  which  formed  the  chromidium. 
So  with  Neuroryctes,  Williams  found  that  buds  appear  as 
small  protuberances  on  the  periphery,  each  protuberance 
receiving  a  portion  of  the  granular  chromidium. 

No  one  doubts  the  fact  that  Entamceba  histolytica  is  an 
organism,  and  an  organism  closely  associated  with,  if  not 
the  cause  of  one  form  of  dysentery,  and  the  time  will  come 
when  no  one  will  doubt  that  Neuroryctes  is  an  amoeboid  or- 
ganism, the  cause  of  hydrophobia.  The  two  organisms  are 
somewhat  alike  in  their  effects,  Entamceba  bringing  about 
a  characteristic  lysis  in  the  wall  of  the  gut,  while  Neuroryctes 
causes  destruction  of  nerve  and  brain  cells. 

Cytoryctes  variolse  is  similar  to  Neuroryctes  and  Ent- 
amceba in  its  general  effect  on  the  tissues,  but  the  tissue 


2;o  SIXTH  INTERNATIONAL 

in  this  case  is  the  skin,  the  most  difficult  of  all  the  tissues 
of  the  body  to  work  with  in  the  laboratory,  because  of  its 
resistance  to  hardening  fluids  and  to  the  knife.  Fixation  of 
the  organ,  therefore,  in  the  skin  cells  or  in  the  cornea  is  no 
better  than  were  the  earliest  attempts  to  fix  the  Negri  body, 
and,  laboring  under  this  technical  disadvantage,  the  life 
history  of  this  organism  is  more  difficult  to  work  out  than 
any  of  the  others.  The  complicated  life  cycle  which  I  de- 
scribed three  years  ago  was  worked  out  on  hardened  material, 
and  at  a  time  before  the  work  on  rhizopods  had  been  done  in 
tracing  the  significance  of  the  chromidium,  and  before  the 
structure  of  the  Negri  body  had  been  described.  The  attempt 
to  account  for  every  stage  observed  in  the  cells  of  the  small-pox 
skin,  led  me  to  suggest  a  complicated  life  history  of  Cytoryctes 
which  is  duplicated  in  only  one  group  of  the  protozoa,  the 
Microsporidia,  and  I  therefore  placed  the  organism  in  the 
order  Microsporidia,  class  Sporozoa.  The  later  researches 
on  rhizopods,  and  especially  on  the  parasitic  amcebae,  Neuro- 
ryctes  and  Entamceba,  have  shown  that  I  was  in  error,  and 
that  the  structures  observed  in  the  different  phases  of  the 
small-pox  organism  correspond  with  different  stages  of 
rhizopod  cell  life. 

The  earliest  of  the  small-pox  forms  is  a  minute  cytoplasmic 
organism  which  resembles  the  young  Neuroryctes.  In  very 
favorable  preparations  from  the  cornea  a  central  spot  which 
takes  a  nuclear  stain  can  be  made  out.  Such  a  nuclear  struc- 
ture is  very  difficult  to  demonstrate,  however,  and  this  stage 
must  be  passed  over  as  uncertain.  There  is  no  uncertainty 
in  regard  to  the  later  cytoplasmic  stages;  and  structures 
appear  which  are  practically  duplicates  of  the  minute  nucleus 
formation  in  free  living  rhizopods,  the  nuclei  arising,  as  in  the 
free  forms,  from  the  substance  of  the  chromidium.  These 
small  nuclei  are  seen  not  only  in  preparations  from  the  skin 
and  cornea,  but  in  fresh  tissue  in  which  they  have  been 
photographed  with  the  aid  of  the  ultra-violet  light. 

Inside  the  nucleus  of  skin  cells  during  the  process  of 
vesicle  formation,  the  organism  presents  a  characteristic 
appearance.  It  is  usually  vesicular,  and  vesicular  in  a  typical 
formation,  recalling  in  a  striking  manner  the  structure  of  the 


DERMATOLOGICAL  CONGRESS  271 

Negri  body  in  preparations  made  before  the  present  technique 
was  established.  In  addition  to  this  typical  form,  other 
intranuclear  bodies  are  present  which  give  striking  evidence 
of  reproductive  phases  more  or  less  similar  to  those  of  the 
cytoplasmic  forms. 

At  the  present  time  I  would  interpret  the  organism  of 
small-pox  as  a  rhizopod  in  which  only  one  phase  of  the  life 
history  is  known,  viz.,  the  asexual  or  vegetative  phase.  This 
is  characterized  by  development  of  the  chromidium  and 
formation  of  small  reproductive  spores  ("gemmules"),  which 
repeat  the  cytoplasmic  cycle.  The  intra-nuclear  forms  possibly 
belong  to  the  sexual  cycle,  and  it  is  not  improbable  that,  as 
Councilman  early  suggested,  the  intra-nuclear  forms  may 
be  a  different  cycle  of  the  organism  occurring  in  variola  and 
not  in  vaccinia.  I  would  interpret  the  vesicular  forms  as 
either  poorly  fixed  organisms,  or  as  degeneration  forms  of  the 
organism,  the  degeneration  being  produced  by  the  accumu- 
lation of  toxins  found  in  the  breaking  down  vesicle.  In 
any  event  the  intra-nuclear  formsof  the  organism  present  a 
different  history  from  that  of  the  cytoplasmic  forms,  and  this 
history  remains  for  some  one  to  work  out  on  well-fixed 
tissue,  or  better,  on  the  living  organism. 

Discussion 

DR.  WALTER  R.  BRINCKERHOPF,  of  Honolulu,  said  he  had  been 
fortunate  enough  to  have  worked  under  Dr.  Councilman  in  his 
studies  on  variola  and  vaccinia,  and  that  a  great  many  problems 
had  been  opened  up  by  this  line  of  study.  It  seemed  to  him  that 
it  would  be  possible  to  carry  out  a  very  important  series  of  ex- 
periments dealing  with  the  problem  of  the  modes  of  the  transmission 
of  the  disease.  It  also  seemed  possible  that  animal  experimen- 
tation might  lead  to  the  discovery  of  a  rational  therapy.  Un- 
fortunately, the  only  animals  so  far  available  were  monkeys,  and 
in  them  we  could  only  produce  one  form  of  small-pox,  i.e.,  variola 
inoculata.  Hence,  to  do  very  effective  work  in  the  study  of  the 
transmission  and  of  the  therapy  of  the  disease  it  would  be  necessary 
to  produce  true  variola,  and  for  that  purpose  animals  nearer  to 
man  than  those  previously  experimented  on  such  as  orangs  or 
chimpanzees  would  be  needed. 

If  we  could  produce  variola  vera  in  one  of  the  lower  animals, 


272  SIXTH  INTERNATIONAL 

we  would  be  able  to  undertake  definite  work  bearing  upon  the 
therapy  of  the  disease.  The  form  of  the  disease  which  could  now 
be  produced  in  the  monkey  was  never  fatal. 

There  were  other  problems,  Dr.  Brinckerhoff  said,  which  bore 
more  directly  upon  the  organism  described  by  Prof.  Councilman. 
One  of  these  was  the  correlation  of  the  different  stages  in  the  de- 
velopment of  the  organism  with  the  clinical  stages  of  the  disease. 
Also,  the  differences  between  the  organism  in  variola  and  vaccinia 
could  be  studied  by  following  the  life  cycle  of  this  organism  in  the 
disease  as  it  was  shown  in  man  and  in  animals.  A  renewal  of 
the  study  of  small-pox  in  animals  was  abundantly  justified  by  the 
persistence  of  variola  as  a  public  health  problem,  which  in  turn 
was  due  to  the  persistence  of  the  non-acceptance  of  the  protective 
power  of  vaccination  against  the  disease. 

DR.  T.  CASPAR  GILCHRIST,  of  Baltimore,  said  he  felt  very  diffi- 
dent in  making  any  statement  in  connection  with  this  subject,  upon 
which  Prof.  Councilman  had  been  accepted  as  an  authority,  and 
who  was  so  well  known  as  an  acute  observer  on  anything  pertain- 
ing to  pathology.  From  the  photographs,  however,  which  Prof. 
Councilman  had  shown,  the  speaker  said  he  could  not  refrain 
from  referring  to  the  similarity  they  bore  to  some  of  the  forms  of 
cell  degeneration  found  in  the  epidermis  in  other  skin  diseases. 
Similar  looking  bodies  he  had  found  particularly  well  demonstrated 
in  a  benign  growth  of  the  skin  which  he  had  reported  in  the  Johns 
Hopkins  Reports,  vol.  i.  In  carcinoma,  also,  somewhat  similar 
bodies  were  found  and  a  number  of  degenerative  epidermal  cell 
bodies  had  been  seen  even  in  herpes  zoster.  Dr.  Councilman's 
argument  that  his  bodies  were  parasites  was  not  well  established. 
The  weakness  of  the  argument  was  shown  in  the  fact  that  the 
parasitic  theory  depended  on  the  morphology  of  the  bodies,  on 
an  incomplete  cycle,  on  the  likeness  to  some  forms  of  rhizopods, 
and  also  upon  similar  bodies  being  formed  in  the  cornea  of  a  rabbit 
after  the  injection  of  vaccine.  Yet  these  bodies  are  only  found 
in  the  epidermis  and  nowhere  else. 

PROF.  COUNCILMAN  said  it  must  be  thoroughly  understood 
that  the  skin  was  not  the  only  place  where  one  found  degenera- 
tion. In  the  course  of  any  active  pathologist 's  work,  and  in 
the  constant  examination  of  histological  specimens,  one  becomes 
in  time  perfectly  familiar  with  the  various  degenerations.  There 
are  many  forms  of  degeneration  characterized  by  the  appear- 
ance of  abnormal  substances  in  cells.  In  some  cases  these  sub- 


DERMATOLOGICAL  CONGRESS  273 

stances  are  the  result  of  changes  taking  place  in  the  cells,  in  others 
they  are  introduced  from  without.  It  would  seem  impossible 
for  any  one  familiar  with  these  conditions  to  confound  them  with 
the  specific  inclusions  which  have  been  shown.  None  of  them  has 
a  distinct  morphology,  while  in  the  organism  found  in  small-pox 
there  is  an  absolutely  distinct  morphology,  as  well  as  all  the  evi- 
dences of  growth.  The  degenerations  referred  to  by  Dr.  Gilchrist 
were  common  and  perfectly  well  known;  one  simply  looked  at 
them  and  passed  them  over.  They  were  found  in  numerous 
conditions,  but  none  of  them  suggested  the  perfectly  definite 
structures  shown  on  the  slides.  The  speaker  was  confident  that 
it  would  not  be  possible  to  get  anything  like  such  a  picture  from 
any  of  the  degenerations. 

PROF.  CALKINS,  in  closing,  said  the  criticism  made  by  Dr. 
Gilchrist  had  already  been  made  about  four  years  ago,  and  since 
that  time  the  work  had  advanced  a  great  deal.  No  one  now,  in 
his  opinion,  would  doubt  that  small-pox  is  a  germ  disease,  and  if 
it  is  due  to  a  germ,  it  must  be  in  the  skin.  This  organism  found 
in  small-pox  can  be  traced  back  through  a  regular  cycle,  and  this 
is  an  argument  that  can  not  be  answered,  even  though  it  is  on  a 
morphological  basis. 


THE  OPSONIC  METHOD  IN  SKIN  DISEASES 
BY  DR.  ARTHUR  WHITFIELD,  OF  LONDON 

In  attempting  to  give  an  account  of  the  method  introduced 
by  Wright  and  Douglas  for  the  diagnosis  and  treatment  of 
bacterial  infections  by  means  of  the  injection  of  appropriate 
vaccines  and  the  estimation  of  their  effects  on  the  blood,  the 
subject  naturally  falls  under  two  headings,  namely,  the  de- 
scription of  the  technique  and  the  results  obtainable  by  the 
method. 

I  do  not  know  whether  or  not  I  am  performing  an  unneces- 
sary task  in  describing  the  technique,  but  since  I  am  pre- 
sumably addressing  an  audience  chiefly  composed  of  those 
who  devote  their  time  to  the  study  of  skin  diseases,  and  it  is 
practically  impossible  to  keep  abreast  of  the  whole  of  medical 
literature,  I  think  it  wise  to  say  a  few  introductory  words  on 
this  part  of  the  subject. 

VOL.  I.— 18 


274  SIXTH  INTERNATIONAL 

Leishman,  while  working  with  Wright,  found  by  mix- 
ing measured  quantities  of  fresh  blood  with  suspensions  of 
various  micro-organisms,  keeping  these  mixtures  for  a  given 
time  at  blood  heat,  and  afterwards  making  stained  films 
from  them,  that  a  variable  number  of  the  micro-organisms 
were  ingested  by  the  phagocytes  in  the  blood  of  different 
individuals.  Wright  and  Douglas,  after  somewhat  modifying 
the  technique,  carried  out  numerous  ingenious  researches 
and  made  several  new  discoveries.  The  method  now  used 
is  shortly  as  follows: 

1.  The  serum  only  of  blood  is  used  and  is  obtained  by 
drawing  off  small  quantities  of  blood  from  a  needle  puncture 
and  allowing  it  to  clot  and  the  serum  to  be  expressed. 

2.  An  emulsion  of  the  bacterium  in  question  is  made  by 
mixing  it  (grinding  if  necessary  in  an  agate  mortar  and  pestle) 
with    a    1.2%  salt  solution  and  centrifugalizing   for  a  short 
time  or  allowing  it  to   stand   for  a  long  time   so  that  the 
larger  masses  may  settle  out.      If  the  tubercle  bacillus  be 
the  organism  used  it  is  necessary  to  heat  it  previously  to 
100°  C.  in  order  to  destroy  its  tendency  to  agglutinate. 

3.  Living   white   corpuscles   are   prepared   by   dropping 
fresh  blood  into  a  normal  saline  solution  containing  also  .5% 
sodium  citrate  to  prevent  clotting,  centrifugalizing  down  the 
corpuscles,  removing  the  citrate  and  substituting  i.  2%  saline, 
again  centrifugalizing,  removing  the  supernatant  saline  and 
then  collecting  and  thoroughly  mixing  the  top  third  of  the 
sediment.     This   forms  an  emulsion   of  red  corpuscles  with 
a  high  percentage  of  white  corpuscles  in  i.  2%  saline. 

By  those  working  with  the  method  this  is  known  for 
convenience  as  "leucocytic  cream"  or  shortly  "cream." 

Before  actually  detailing  the  method  of  procedure  it  may 
be  well  to  offer  a  few  explanatory  remarks.  As  there  is  at 
present  no  fixed  point  to  work  from  in  estimating  the  number 
of  bacilli  which  should  be  taken  up,  it  is  necessary  to  com- 
pare the  blood  under  examination  with  that  of  a  normal 
person,  or  the  mixed  bloods  of  many  normal  persons,  often 
designated  a  "pool." 

The  normal  standard  is  arbitrarily  fixed  at  i.o  and  devia- 
tions from  this  are  reckoned  in  decimal  fractions  on  either 


DERMATOLOGICAL  CONGRESS  275 

side  of  the  normal.     The  following  experiments  have  been 
carried  out  by  Wright  and  Douglas,  and  others: 

1.  The  leucocytes  of  a  tuberculous  patient  and  the  serum 
of  a  normal  person   +  tubercle  bacilli  give  a  result  identical 
with  that  obtained  when  the  same  serum  and  emulsion  are 
associated  with  leucocytes  obtained  from  a  normal  person. 

2.  The  leucocytes  of  a  normal  person  and  serum  of  a 
tuberculous  person  +  bacillary  emulsion  give  the  same  results 
as  those  obtained  when  tuberculous  leucocytes  are  associated 
with  tuberculous  serum  and  bacillary  emulsion.     From  these 
experiments  is  deduced  the  fact  that  in  variations  of  phago- 
cytosis the  cause  of  the  variation  lies  with  the  serum  and  not 
with  the  leucocytes. 

3.  Heating  the  serum  to  60°  C.  before  use  causes  it  to 
lose  its  power  of  inducing  phagocytosis. 

4.  If,  however,  the  serum  be  mixed  with  the  bacillary 
emulsion,  allowed  to  stand  for  some  time  at  body  heat,  and 
the  mixture  then  heated  to  60°  C.  for  ten  minutes  the  results 
obtained  with  the  heated  mixture  are  similar  to  those  obtained 
with  an  unheated  mixture. 

It  is  therefore  agreed  that  the  action  of  the  serum  is  one 
upon  the  bacilli  and  not  the  leucocytes,  and  this  action  once 
established  is  not  destroyed  by  heating  to  60°  C.  Having 
thus  proved  the  presence  in  blood  serum  of  a  body  which  is 
capable  of  acting  on  bacilli  and  rendering  them  easy  of  phago- 
cytosis by  the  leucocytes,  Wright  and  Douglas  then  named 
this  new  body  "Opsonin"  from  opsonio  "I  prepare  a  feast." 

To  perform  an  estimation,  amounts  of  cream  and  bacillary 
emulsion  are  prepared  sufficient  for  several  observations,  since 
it  is  essential  that  in  comparing  two  or  more  sera  the  cream 
and  emulsion  shall  remain  the  same.  It  is  also  of  paramount 
importance  that  the  sera  to  be  tested  shall  have  been  drawn 
from  the  body  at  approximately  the  same  time  and  kept  under 
the  same  conditions,  since  changes  take  place  in  the  sera  after 
being  withdrawn  from  the  body,  these  changes  being  first  a 
rise  and  then  a  fall  in  the  opsonic  power. 

Having  the  sera,  the  cream,  and  the  bacillary  emulsion  in 
readiness,  a  moderately  fine  pipette  is  fitted  with  a  rubber 
teat,  a  number  marked  on  the  thick  part  and  a  small  mark 


276  SIXTH  INTERNATIONAL 

made  on  the  capillary  portion  about  an  inch  from  the  end. 
Cream  is  drawn  up  to  the  mark  on  the  tube,  the  point  is  then 
removed  from  the  vessel  containing  the  cream  and  the  column 
allowed  to  slide  about  a  quarter  of  an  inch  up  the  tube,  which 
is  then  wiped.  Bacillary  emulsion  is  then  drawn  up  in  the 
same  way,  the  volume  being  separated  from  that  of  the  cream 
by  a  small  column  of  air.  Now  another  column  of  air  is 
taken  and  finally  a  volume  of  serum.  The  reason  for  this 
order  is  that  the  cream  being  rather  thick  offers  a  good  deal 
of  resistance  to  being  drawn  up  and  consequently  the  column 
remains  steady  and  is  easy  to  adjust,  the  jerking  backwards 
and  forwards  of  the  column  being  a  great  source  of  difficulty 
to  the  beginner.  Serum  is  taken  last  because  this  is  the 
variable  quantity,  and  the  slightest  contamination  of  the  other 
fluids  by  it  might  vitiate  the  whole  experiment.  Personally 
I  always  take  two  volumes  of  cream  to  one  of  each  of  the 
others,  as  I  find  I  get  better  films  in  this  way. 

In  the  original  method  of  Wright  and  Douglas  normal 
saline  was  used  to  sustain  the  corpuscles  and  bacilli,  but  from 
experiments  these  observers  made  it  was  found  that  a  certain 
amount  of  "spontaneous"  phagocytosis  occurred  in  the 
absence  of  all  serum,  and  this  was  reduced  to  a  minimum  by 
the  use  of  i.  2%  saline. 

As  soon  as  the  three  volumes  are  obtained  they  are  blown 
out  on  to  a  clean  slide  and  thoroughly  mixed  by  alternately 
sucking  up  and  blowing  out,  bubbles  being  avoided.  The 
mixture  is  then  drawn  up  into  the  pipette  in  a  single  column, 
the  end  sealed,  and  the  tube  placed  in  the  incubator  at  blood 
heat  for  a  quarter  of  an  hour.  In  practice,  as  soon  as  one 
tube  is  put  in  the  chamber  another  is  got  ready,  so  as  to  have 
a  series  going.  I  find  I  can  easily  get  eight  tubes  in  in  a 
quarter  of  an  hour  and  have  done  as  many  as  ten  in  this  time. 
At  the  end  of  the  period  each  tube  is  taken  out,  the  end  broken 
off,  the  contents  again  thoroughly  mixed,  and  films  made  and 
stained.  For  fixing  the  films  saturated  perchloride  of  mercury 
is  used,  for  staining  the  tubercle  bacillus  hot  carbol-fuchsin, 
followed  by  2.5%  H2SO4,  as  recommended  by  Wright,  and 
an  after-stain  of  borax-methylene  blue.  For  other  organisms 
the  blue  alone  gives  good  results.  Having  obtained  the 


DERMATOLOGICAL  CONGRESS  277 

films,  one  counts  the  number  of  bacilli  taken  up  by  a  definite 
number  of  leucocytes  (I  count  forty)  in  the  control  and  com- 
pares this  with  the  number  taken  up  in  the  samples  to  be 
investigated,  and  thus  one  obtains  the  opsonic  index. 

Having  thus  described  the  method  I  may  now  pass  on  to 
the  results  obtainable  by  it.  The  first  question  which  arises 
is:  Are  these  figures  reliable?  Now,  full  as  the  method  is  of 
apparent  sources  of  error,  my  mind  is  quite  made  up  on  this 
point.  With  a  good  technique  in  experienced  hands,  an  error 
of  5%,  or  at  the  outside  10%,  may  occur.  I  state  this  with 
confidence,  because  for  nearly  three  years  I  have  had  a  friend 
working  next  door  to  me  in  the  laboratory,  and  to  save  time 
the  first  down  in  the  laboratory  makes  cream  and  bacillary 
emulsion  for  both.  We  use  our  own  bloods  as  controls  and 
we  have  compared  notes  on  so  many  occasions  and  found 
almost  invariably  an  error  of  less  than  5%  that  I  feel  sure  of 
my  ground.  Also,  on  many  occasions  when  Wright  was 
dealing  with  a  case  and  I  took  the  samples  I  have  taken  two 
samples  and  worked  one  out  on  my  own  account  to  control 
my  own  accuracy.  Occasionally,  it  is  true,  something  may 
go  wrong  with  an  estimation,  but  it  can  practically  always 
be  suspected  and  the  estimation  rejected.  On  the  other 
hand,  I  do  not  wish  to  make  out  that  the  technique  is  acquired 
in  a  few  minutes,  because  it  is  not  so,  and  I  have  seen  with  deep 
regret  all  kinds  of  perfectly  ludicrous  statements  published, 
evidently  based  on  bad  technique  of  the  crudest  variety. 

Next  we  may  inquire  in  what  way  the  estimation  of  the 
opsonic  index  may  be  of  use  to  us  in  practical  medicine. 
There  are  two  ways  in  which  it  may  be  used,  namely,  as  a 
means  of  diagnosis,  and  as  an  aid  to  the  regulation  of  dosage 
in  treatment. 

In  the  first  place,  it  has  been  suggested  that  the  opsonin 
is  the  chief  defensive  body,  but  I  do  not  think  Wright  himself 
has  ever  strongly  asserted  this,  and  in  conversation  with  me 
he  has  stated  his  belief  that  it  is  only  one  of  the  defensive 
bodies  produced  by  the  host. 

It  is  possible,  however,  that  the  opsonic  index  varies  with 
that  of  the  immunity  as  a  whole  and  is  therefore  a  true  index 
of  the  power  of  resistance  of  the  patient.  From  several 


278  SIXTH  INTERNATIONAL 

observations  I  believe  this  to  be  generally  the  case,  but  I  am 
positive  that  it  is  not  invariably  so.  I  have  carefully  watched 
a  case  in  which  the  disease  was  progressing  and  in  which  new 
foci  were  appearing  while  the  index  as  examined  twice  a  week 
was  steadily  high.  Here  I  regret  to  say  that  I  am  in  oppo- 
sition to  Wright,  who  believes  that  the  high  index  associated 
with  infection  is  never  maintained,  but  is  only  a  phase  in  the 
oscillations. 

In  the  examination  of  the  index  in  a  large  number  of 
healthy  persons  Bulloch  found  that  it  ranged  between  .8  and 
1.2,  but  I  would  point  out  that  these  extremes  were  very  rarely 
met  with  and  that  the  vast  majority  of  Bulloch's  observations 
fell  between  .9  and  1. 1.  On  the  other  hand,  if  a  number  of 
diseased  patients  be  examined  it  will  be  found  that  few  lie 
within  the  normal  limits  for  any  considerable  period.  Most 
are  found  to  be  low,  .8  and  under,  while  a  good  many  are  high, 
1.3  and  over,  and  I  have  already  stated  that  Wright  believes 
that  the  high  cases  are  either  dealing  satisfactorily  with  a 
lesion  or  are  oscillating.  Certainly  oscillation  is  a  marked 
symptom  suggesting  infection  in  a  doubtful  case,  and  it  is 
therefore  well  to  take  two  or  three  observations  before  making 
a  diagnosis  or  even  commencing  treatment  in  a  case  where 
the  disease  is  known.  From  the  diagnostic  point  of  view, 
therefore,  we  may  say  that  a  high,  low,  or  oscillating  index 
is  suggestive  of  infection  with  the  organism  in  question. 

Referring  back  one  moment  to  the  question  as  to  whether 
the  opsonin  is  the  only  important  body  in  immunity  in  those 
diseases  due  to  a  bacillus  which  is  chiefly  endotoxic,  my 
friend,  Dr.  Briscoe,  has  performed  some  very  interesting 
experiments.  It  is  well  known  that  heating  to  60°  C.  destroys 
the  opsonins.  Dr.  Briscoe  immunized  animals  to  different 
bacilli  (actually  to  Friedlander's  pneumo-bacillus  and  to 
staphylococcus  pyogenes)  on  three  occasions,  and  when  their 
opsonic  index  was  high  drew  off  some  of  their  blood,  exposed 
it  to  a  temperature  of  60°  C.,  determined  the  opsonic  index 
in  the  heated  serum  and  found  it  practically  zero,  and  then 
injected  equal  parts  of  the  heated  serum  and  bacillary  emulsion 
into  animals,  using  as  a  control  equal  parts  of  the  same  bacillary 
emulsion  and  salt  solution.  In  the  case  of  a  very  virulent 


DERMATOLOGICAL  CONGRESS  279 

pneumo-bacillus  the  control  died  in  ten  hours,  whereas  the 
animal  which  received  the  heated  immune  serum  mixed 
with  the  bacilli  survived  three  days,  while  with  less  virulent 
organisms  the  control  animal  died  and  the  experimental 
animal  was  not  ill.  This  would  indicate  that  there  is  another 
body  present  besides  the  opsonin,  but  the  opsonic  index  being 
high  at  the  same  time,  it  may  be  that  the  index  is  reliable  to 
show  the  state  of  immunity  of  the  blood. 

The  heat  test  has  been  used  also  as  an  aid  to  diagnosis 
since  it  has  been  found  that  the  opsonin  present  after  inocu- 
lation and  in  those  suffering  from  the  disease  is  not  so  entirely 
destroyed  by  heat.  This  appears  to  me  to  be  quite  unreliable, 
since  a  patient  of  mine  who  had  had  numerous  injections  of 
tuberculin,  some  of  them  very  recent,  fell  from  .95  to  .14  after 
heating  for  ten  minutes  to  56.5°  C.  Lawson,  of  Banchory, 
maintains  that  a  negative  phase  after  the  injection  of  a  minute 
dose  of  vaccine  is  actual  evidence  of  infection,  and  although 
I  have  not  done  much  work  on  the  subject,  what  I  have  done 
corroborates  this  view. 

We  have  therefore  for  diagnosis  three  ways  of  using  the 
opsonic  index. 

1.  Gross  variation  of  the  index   from  the  normal,   or 
marked  fluctuation. 

2.  Persistence   of   the   opsonin    after   heating    (positive 
evidence  only). 

3.  Marked  negative  phase  after  inoculation. 

I  may  now  pass  on  to  the  therapeutic  use  of  the  opsonic 
method  in  skin  disease.  The  three  micro-organisms  which 
commonly  affect  the  skin  are  (i)  the  staphylococcus,  (2)  the 
streptococcus,  (3)  the  tubercle  bacillus,  and  besides  these 
there  are  other  less  commonly  found  infections  such  as  are 
met  with  in  some  ecthymatous  sores. 

The  streptococcus  appears  to  cause  two  main  classes  of 
disorder,  namely,  an  epidermic  infection  and  a  corium  in- 
fection. The  former  may  be  acute  (impetigo),  or  chronic 
(Sabouraud's  chronic  streptococcic  dermatitis).  The  acute 
needs  no  opsonic  treatment,  since  it  is  so  easily  cured  without 
it,  and  in  the  chronic  the  infection  is  so  mixed  that  it  is  difficult 
to  estimate  the  etiological  importance  of  the  various  organisms. 


28o  SIXTH  INTERNATIONAL 

I  am  inclined  to  think,  however,  that  Sabouraud  has  over- 
estimated the  importance  of  the  streptococcus  in  this  disease. 
The  chronic  relapsing  lymphangitis  or  deep  streptococcal 
dermatitis  would  be  a  very  suitable  case  for  inoculation  were 
it  not  for  the  difficulty  of  obtaining  the  particular  organism 
from  the  case.  And  I  must  here  emphasize  the  fact  that  in 
streptococcal  infections  it  is  of  the  highest  importance  to  use 
the  culture  derived  from  the  particular  case,  as  a  patient  may 
show  a  high  index  to  one  strain  of  streptococcus  and  a  very 
low  one  to  his  own.  For  these  reasons  I  shall  confine  myself 
to  the  staphylococcus  and  the  tubercle  bacillus.  The  in- 
fections with  the  staphylococcus  may  be  primary  or  secondary, 
and  in  the  latter  case  may  have  a  very  variable  importance 
in  the  production  of  the  disease. 

The  primary  forms  are,  of  course,  the  boil  or  carbuncle 
and  sycosis.  Sycosis  differs  from  the  others  in  that  the 
organism  is  shut  off  from  the  body  generally  by  the  epithe- 
lial barrier  of  the  root  sheath,  which  undoubtedly  renders  it 
more  difficult  of  approach  by  the  opsonic  method.  As  re- 
gards the  treatment  of  boils  I  may  say  that  in  my  hands  it 
has  been  a  complete  and  brilliant  success,  and  every  case 
whose  after-history  has  reached  me  has  been  permanently 
cured.  The  largest  number  of  injections  given  has  been  eight, 
and  the  dose  has  ranged  from  250  to  1000  millions  of  staphy- 
lococci.  One  or  two  patients  have  had  a  boil  after  the  treat- 
ment has  been  begun,  but  most  have  had  no  more  after  the 
first  injection. 

Sycosis  has  proved  more  resistant  and  although  I  have 
never  failed  to  cause  immediate  improvement,  the  condition 
has  been  apt  to  relapse,  more  especially  in  those  cases  in  which 
the  disease  has  been  set  up  by  nasal  discharge  and  in  which 
there  is  a  great  susceptibility  to  ordinary  coryza.  I  have 
on  more  than  one  occasion  combined  the  inoculation  with 
epilation  by  means  of  the  X-rays,  and  I  think  this  is  of  dis- 
tinct advantage,  but  I  have  seen  relapse  occur  in  lip  cases 
after  the  hair  has  grown  again.  Sycosis  is  much  commoner 
in  hospital  than  in  private  cases  and  consequently  one  is 
seldom  able  to  keep  the  patient  under  treatment  until  a 
permanent  cure  is  established. 


DERMATOLOGICAL  CONGRESS  281 

Of  the  secondary  staphylococcic  infections,  acne,  pustular 
dermatitis,  and  septic  ulcers  are  the  chief  examples. 

With  the  treatment  of  acne  I  have  been  disappointed  in 
some  cases.  Looking  through  my  notes  I  find  that  five  cases 
gave  brilliant  results,  after  the  failure  of  many  other  forms 
of  treatment  by  eminent  specialists.  One  case  improved 
greatly,  then  fell  away  again,  owing  to  general  ill-health 
and  dyspepsia,  after  which  he  threw  up  the  treatment  and 
was  for  months  afterward  treated  very  vigorously  by  his 
family  doctor  under  the  guidance  of  a  specialist,  and  then 
spent  some  months  in  Scotland  in  the  country.  His  doctor 
told  me,  however,  that  his  disease  was  only  very  slightly 
ameliorated,  and  both  he  and  I  thought  that  he  did  better 
under  the  inoculation  than  the  ordinary  treatment.  One 
case  always  improved  at  once  after  each  injection,  but  fell 
away  again  at  the  end  of  a  week  and  finally  gave  up  the 
treatment.  This  patient  had  a  strong  family  history  of 
diabetes  on  both  sides  of  her  family,  and  had  suffered  a  good 
deal  from  general  ill-health,  though  there  were  no  signs  of 
diabetes  present.  Three  cases,  one  of  them  very  severe  and 
apparently  the  ideal  case  for  inoculation,  sent  me  by  Dr. 
Pringle,  showed  no  improvement,  although  I  used  vaccines 
made  from  their  own  organisms.  One  case  in  which  I  could 
never  get  the  organisms  to  grow  freely  enough  for  use  did  not 
improve.  This  patient  was  a  terrible  sufferer  from  menstrual 
and  inter-menstrual  pain. 

The  septic  dermatitis  cases  have  all  done  moderately 
well  and  some  brilliantly.  It  appears  to  depend  on  the  degree 
in  which  the  staphylococcus  is  responsible  for  the  cutaneous 
irritability  as  well  as  the  pustulation.  I  have  only  treated 
one  ulcer  of  nine  years'  standing,  by  means  of  inoculation 
on  the  distal  side.  This  healed  after  four  inoculations,  but 
broke  down  again  after  an  attack  of  influenza.  The  patient 
was  about  the  whole  time  and  the  ulcer  was  immediately 
above  the  ankle. 

Turning  to  tuberculosis  I  have  treated  two  cases  of  Bazin's 
disease  and  several  of  lupus  vulgaris.  In  one  case  of  Bazin's 
disease  the  inoculation  was  the  only  treatment  which  did 
good  during  four  years'  observation.  The  index  when  first 


282  SIXTH  INTERNATIONAL 

examined  was  .35,  and  new  nodules  were  coming  out.  After 
inoculation  the  index  was  easily  kept  above  i.o  and  all  the 
nodules  immediately  resolved,  although  before  this  neither 
the  patient  nor  I  had  ever  observed  a  nodule  which  did  not 
liquefy  and  burst.  Treatment  was  continued  for  about  six 
months  and  then  the  patient  stopped  attending.  Three 
months  later  she  reappeared  with  new  nodules  and  the  index 
was  found  to  be  i.  2.  This  high  index  was  maintained  though 
nodules  kept  appearing,  and  eventually  inoculations  were  tried, 
but  were  unavailing.  She  was  taken  into  the  hospital  and 
the  index  examined  twice  a  week  and  it  was  found  always 
high.  Not  until  the  last  nodule  had  formed  and  burst  did  it 
fall  to  .9. 

Turning  to  my  cases  of  lupus  vulgaris,  I  may  say  that  in  all 
cases  except  one  the  disease  appeared  to  be  arrested,  though 
the  natural  spread  is  so  slow  that  it  is  difficult  to  say  how  much 
is  due  to  the  treatment.  In  the  one  case  in  which  spread  took 
place  the  patient,  a  boy  aged  ten,  was  in  very  poor  circum- 
stances and  had  absolutely  no  appetite.  A  great  deal  of 
careful  general  treatment  did  something  to  improve  his  con- 
dition, but  I  was  unable  to  keep  his  index  up  with  any  degree 
of  certainty  and  eventually  he  was  taken  into  the  hospital 
and  the  patch  excised.  In  no  case  of  lupus  treated  by  me 
have  I  seen  marked  improvement  unless  the  case  has  also 
been  under  X-ray  or  light  treatment,  yet  I  have  cases  which 
have  been  carefully  opsonized  for  nearly  three  years.  On  the 
other  hand,  I  have  seen  a  few  cases  of  Wright's  in  which  un- 
doubted improvement,  almost  to  the  point  of  cure,  has  taken 
place. 

Of  course,  with  his  complete  staff  of  workers  a  difficult  case 
can  be  opsonized  daily,  but  I  venture  to  think  that  the  results 
of  opsonic  treatment  alone  in  lupus  are  slow  and  uncertain. 
Lupus,  however,  is  not  well  understood,  and  it  may  well  be 
that  there  are  additional  factors  besides  the  tuberculosis 
which  militate  against  our  success. 

CONCLUSIONS 

I  may  state  that  I  believe  that  the  opsonic  method  fore- 
shadows an  enormous  advance  in  our  control  over  infective 


DERMATOLOGICAL  CONGRESS  283 

disorders,  but  that  at  present  there  exists  a  great  hiatus 
in  our  knowledge  which  renders  the  results  uncertain  in  some 
cases.  The  following  conclusions  are,  however,  based  on  long 
and  steady  work  at  the  method,  and  are,  I  hope,  stated  with 
reasonable  impartiality. 

1.  The  opsonic  treatment  of  boils  is  uniformly  successful 
and  is  the  only  form  of  treatment  for  general  furunculosis 
which  is  in  the  slightest  degree  reliable. 

2.  In  sycosis  the  treatment  is  a  valuable  aid,  but  must  be 
continued  for  long  periods  in  proportion  to  the  duration  of 
the  disease,  and  it  is  best  combined  with  X-ray  depilation. 

3.  In  acne  the  treatment  is  uncertain,  in  some  cases 
being  most  brilliant,  in  others  without  the  slightest  avail. 

4.  In  septic  dermatitis  and  ulcers  the  treatment  is  of 
very  distinct  value  as  an  auxiliary. 

5.  In   Bazin's   disease  the  treatment  is   somewhat  un- 
certain, but   it   is  sometimes  of  assistance.     In  tuberculous 
ulceration  it  is  of  great  value. 

6.  In  lupus  the  treatment  alone  is  too  slow  and  uncertain 
to  be  recommended.     It  is,  according  to  Bulloch,  a  valuable 
auxiliary  in  preventing  relapse  after  Finsen's  treatment,  and 
I  have  found  it  of  value  combined  with  the  X-rays. 


BACTERIAL  INOCULATION  IN  THE  TREAT- 
MENT OF  SUPPURATIVE  AND  TUBERCU- 
LOUS DISEASES  OF  THE  SKIN  AFTER  THE 
METHOD  OF  WRIGHT 

BY  DR.  E.  M.  VON  EBERTS,  OF  MONTREAL 

Towards  the  close  of  1900,  Professor  Wright  of  St.  Mary's 
Hospital,  London,  stimulated  by  the  change  observed  in  the 
blood  of  those  inoculated  with  anti-typhoid  vaccine,  con- 
ceived the  idea  of  exploiting  bacterial  inoculation  in  the 
treatment  of  localized  suppurative  (staphylococcic)  affections 
of  the  skin,  and  in  the  Lancet  of  March  29,  1902,  appeared  an 
account  of  the  clinical  results  achieved  in  the  treatment  of 
six  cases,  representing  such  varied  forms  of  staphylococcic 
invasion  as  furunculosis,  acne  and  sycosis;  while  in  May, 
1904,  from  the  laboratory  of  the  same  investigator,  appeared 
the  results  obtained  in  the  treatment  of  a  series  of  eighteen 
cases  of  staphylococcic  infection  by  the  same  method.  Since 
this  earlier  work,  Wright  and  Douglas,  Bulloch,  Weinstein, 
Hektoen,  Potter,  Webb,  and  Varney  are  but  a  few  among 
many  who  have  exploited  this  form  of  therapy  with  satisfactory 
results,  especially  in  the  more  acute  forms  of  staphylococcic 
skin  affections. 

This  new  therapy  came  to  the  fore  as  the  end  product  of 
many  years  of  experimental  work  by  different  investigators. 
The  corner-stone  of  the  opsonic  theory  may  be  said  to  have 
been  laid  by  Denys  and  Leclef,  who,  in  1895,  proved  the 
existence  in  the  serum  of  vaccinated  animals  of  a  substance 
capable  of  altering  bacteria  in  such  a  way  as  to  permit  of  their 
inception  by  the  phagocytes  of  the  blood,  and  concluded  that 
vaccinated  animals  were  able  to  withstand  infection,  first, 
by  the  direct  action  of  the  serum,  and,  secondly,  by  the  leuco- 
cytes. The  work  of  these  observers  was  substantiated  by 

284 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS;        285 

Mennes  in  1897,  and  Leishman  in  1902;  the  latter  devising 
a  technique  for  the  quantitative  estimation  of  the  phagocytic 
power  of  different  sera.  Then  followed  the  clinical  experi- 
ments of  Wright  and  Douglas  upon  "The  Role  of  Blood  Fluids 
in  Connection  with  Phagocytosis,"  in  which  they  conclusively 
demonstrated  the  existence  in  the  blood  serum  of  a  definite 
element,  which,  when  brought  into  contact  with  bacteria, 
rendered  such  more  acceptable  to  the  phagocytic  leucocytes. 
To  this  element  was  given  the  name  opsonin.  It  was  further 
concluded  that  the  fluctuations  in  the  phagocytic  index  fol- 
lowing inoculation  were  due  to  the  presence  in  the  serum  of  a 
varying  amount  of  opsonin,  and  that  the  opsonic  content  and 
phagocytic  index  were  practically  interchangeable  expressions 
of  varying  degrees  of  immunity  toward  a  given  infection. 
The  connection  between  laboratory  and  clinic  was  at  once 
established,  with  the  observation  that  a  depressed  immunity 
(negative  phase)  coincided  with  exacerbations  in  the  local 
symptoms,  and  that  heightened  immunity  was  the  forerunner 
and  sustainer  of  improved  clinical  phenomena;  and  finally, 
that  inoculation  with  specific  vaccines  was  generally  followed 
by  an  ebb,  flow  and  reflow  in  the  immunity  curve. 

The  technique  of  opsonic  determinations  has  been  so 
widely  commented  upon,  that  I  purpose  to  touch  only  upon 
the  more  salient  points.  For  such  determinations  sera  from 
patients  and  controls  should  be  collected  at  the  same  time 
each  day,  and  slides  prepared  within  six  hours,  as  after  this 
period  has  elapsed  a  gradual  decrease  in  the  opsonic  element 
takes  place,  amounting  in  twenty-four  hours  to  approximately 
50  per  cent. 

Washed  corpuscles  should  always  be  prepared  from  the 
same  individual  and  immediately  before  use,  as  in  those 
which  have  stood  for  more  than  four  hours,  a  gradually  in- 
creasing number  of  the  polynuclear  neutrophiles  fail  to  func- 
tionate. This  loss  of  phagocytic  function  may  be  postponed 
within  limits  by  allowing  a  small  portion  of  the  saline  to  re- 
main after  washing,  until  immediately  before  use.  It  is 
most  important  at  all  times  in  the  preparation  of  washed 
cells  to  avoid  centrifugalizing  beyond  the  actual  time  necessary 
to  produce  a  well-defined  "buffy  coat,"  as  in  prolonged  cen- 


286  SIXTH  INTERNATIONAL 

trif legalization  the  "blood  cream"  becomes  corrugated  on  its 
surface  layer,  with  compaction  and  distortion  of  the  leuco- 
cytes, many  of  which  suffer  loss  of  function. 

Bacterial  suspensions  should  be  freshly  prepared  from 
six-  to  eight-hour  cultures  of  the  homologous  organism,  em- 
ploying 0.85  per  cent,  saline  solution  as  yielding  the  minimum 
of  spontaneous  phagocytosis.  In  the  preparation  of  tubercle 
suspensions,  i.  5  per  cent,  saline  solution  should  be  used. 

A  tubular  thermostat  is  indispensable  for  the  accurate 
incubation  of  the  admixed  serum,  suspension  and  washed 
cells. 

In  the  preparation  of  bacterial  vaccines  apart  from  the 
fundamental  requirement  that  such  shall  be  closely  affiliated 
to  the  organism  producing  the  disease  which  it  is  desired 
to  combat,  there  are  many  details  of  minor  importance  which 
enhance  very  largely  the  probabilities  of  success. 

In  the  first  place,  it  is  important  that  a  vaccine  should  be 
prepared  from  the  original  culture  or  first  transplant.  It  is 
sometimes  possible  to  employ  the  former  where  care  is  taken 
in  the  transference  of  material  -from  the  lesion  to  the  tube 
to  insure  an  even  distribution  of  the  same  over  the  entire 
surface  of  the  slant.  Early  cultures  are  especially  of  im- 
portance as  retaining  as  far  as  possible  the  personal  element 
in  the  infection. 

Experience  shows  that  eighteen-hour  cultures  are  the  most 
suitable  for  vaccines,  as  at  this  time,  not  only  is  the  growth 
of  the  organism  mature,  but  desiccation  in  the  tube  has  not 
proceeded  to  a  point  where  difficulty  is  encountered  in  breaking 
up  by  simple  agitation  the  smaller  bunches  of  cocci — an  im- 
portant point  in  connection  with  standardization. 

Devitalization  should  be  effected  at  the  lowest  possible 
temperature,  that  commonly  employed  being  60°  centigrade 
for  one  hour,  a  period  invariably  sufficient  to  prevent  growth 
in  control  tubes  with  the  exception  of  an  occasional  aureus 
infection.  It  is  possible  that  fractional  devitalization  at  a 
lower  temperature  might  yield  more  active  vaccines.  The 
temperature  at  which  devitalization  is  effected  is,  next  to  the 
source  of  the  organism  employed,  the  most  important  factor 
in  the  determination  of  the  composition  of  the  vaccine. 


DERMATOLOGICAL  CONGRESS  287 

As  I  have  stated  elsewhere,  it  is  my  opinion  that  "stock" 
vaccines  are  permissible  in  the  treatment  of  certain  aureus 
infections,  such  as  furunculosis  and  impetigo,  providing  al- 
ways that  the  "stock"  employed  has  been  prepared  from 
the  organism  isolated  in  a  similar  clinical  condition.  Of 
course,  where  a  case  fails  to  yield  at  once,  a  personal  or  auto- 
genous vaccine  should  be  employed  for  subsequent  injections. 
In  the  conduct  of  cases  of  acne  indurata  and  coccogenous 
sycosis  personal  vaccines  should  in  every  case  be  prepared. 
Failure  or  only  partial  success  in  the  handling  of  such  cases 
has  been  largely  due  to  the  inattention  paid  in  the  past  to 
the  question  of  autogenous  vaccines. 

In  the  treatment  of  tuberculous  infections  of  the  skin,  the 
question  of  autogenous  vaccines  is  at  present  impracticable, 
but  very  encouraging  results  may  be  obtained  with  Koch's 
new  tuberculin  (T.  R.). 

Dosages. — Increasing  experience  shows  that  the  doses 
originally  employed  in  staphylococcic  infections  were  too 
large,  so  that  at  the  present  time  instead  of  500  millions  or 
more  being  injected  at  the  initial  dose,  it  has  been  found  ad- 
visable to  start  with  100  or  200  millions,  or  in  a  tuberculous 
case  ^oV-g-  to  -r^Vr  m.  gm.  of  T.  R.,  deciding  as  to  the  effect 
and  subsequent  dosage  by  the  immunity  reaction  induced  in 
the  individual,  as  interpreted  by  the  opsonic  findings.  If 
the  negative  phase  following  inoculation  is  severe  or  pro- 
longed, the  dose  should  be  diminished.  Where,  on  the  other 
hand,  the  immunizing  response  is  inadequate — that  is,  where 
the  negative  phase  is  suppressed  and  the  positive  phase  but 
slight — the  dosage  should  be  increased. 

Subsequent  inoculations  should  not  be  regulated  by  the 
antiquated  hypothetical  "fixed  period"  of  ten  days,  but 
should  be  undertaken  with  each  successive  decline  or  reflow 
in  the  immunity  on  the  fifth,  seventh,  or  tenth  day  as  the 
opsonic  findings  indicate.  In  the  use  of  tuberculin  it  is  as 
well  to  make  each  inoculation  a  separate  event,  as  reinocu- 
lation  seldom,  if  ever,  in  this  infection,  leads  to  a  cumulation 
in  the  direction  of  a  positive  phase. 

More  attention  should  be  paid  in  future  to  the  site  of 
inoculation.  Everyone  who  is  familiar  with  the  local  reaction 


288  SIXTH  INTERNATIONAL 

which  sometimes  follows  the  subcutaneous  injection  of  tuber- 
culin, must  have  been  impressed  with  the  fact  that  such  cases 
showed  more  pronounced  improvement  than  is  generally  met 
with.  Such  experience  coincides  with  the  observations  of 
Wright  in  connection  with  the  subcutaneous  inoculation  of 
typhoid  vaccine,  where  it  was  found  that  local  reactions  were 
associated  with  an  immunity  response  very  much  greater  than 
in  those  inoculated  intravenously,  and  possibly  the  subjects 
of  marked  constitutional  symptoms.  The  elaboration  of 
protective  elements  locally  at  the  seat  of  inoculation  is  further 
substantiated  by  the  observation  that  in  horses  a  greater 
yield  of  antitoxins  is  secured  by  subcutaneous  rather  than 
by  intravascular  injections.  While  personally,  I  have  not 
had  the  opportunity  of  deciding  upon  a  method  apparently 
most  suitable  to  the  treatment  of  certain  selected  cases  of 
lupus  or  tuberculous  ulceration  of  the  skin,  I  am  assured  by 
Professor  Wright  that  he  has  achieved  brilliant  results  by 
placing  inoculations  on  the  side  of  the  lesion  distal  to  the 
lymph  glands  draining  the  part,  disposing  the  same  circle-wise ; 
care  being  taken  to  avoid  the  too  frequent  use  of  the  same 
site. 

In  the  conduct  of  cases  of  acne  indurata,  especially  those 
of  long  standing,  where  the  presence  of  scar  tissue  has  ma- 
terially impaired  the  cutaneous  blood  supply,  I  have  employed 
daily  applications  of  hot  water  stupes  for  a  period  of  fifteen 
to  twenty  minutes,  with  a  view  to  dilating  the  vessels  and 
determining  immune  serum  to  the  part;  that  is,  a  serum  rich 
in  opsonins. 

As  before  stated,  the  personal  vaccine  is  an  element  of 
importance  in  the  treatment  of  at  least  fifty  per  cent,  of  these 
cases. 

Dosage  and  the  spacing  of  inoculations  should  be  regulated, 
at  the  start  at  any  rate,  by  careful  opsonic  determinations. 

From  my  own  experience  and  from  conversation  with 
other  workers  in  this  field,  I  am  of  the  opinion  that  a 
judicious  selection  of  cases  is  not  always  made,  and  that 
the  statistics  so  far  published,  embrace  under  the  head- 
ing of  acne  indurata  numerous  affections  such  as  acne 
rosacea,  comedones  associated  with  suppuration  and  the 


DERMATOLOGICAL  CONGRESS  289 

acneiform  eruption  so  common  upon  the  chin  and  forehead 
during  menstruation.  These  aberrant  forms  of  acne  are 
apparently  not  benefited  to  the  same  extent.  In  the  treatment 
of  true  acne  indurata,  I  have  yet  to  meet  a  case  in  which 
marked  improvement  after  the  first  inoculation  was  absent. 
In  long-standing  cases,  the  eruption  becomes  much  more 
discrete;  the  papules  seldom  proceeding  to  suppuration  and 
scarring.  Cases  which  do  not  yield  promptly  are  those 
in  which  the  initial  index  is  not  found  to  be  greatly, 
if  at  all,  depressed.  In  such  cases  inoculation  can  only  be 
considered  a  valuable  additional  weapon.  The  above  state- 
ment develops  the  opinion  that  the  primary  index  has  a 
definite  bearing  upon  the  prognosis;  where  it  is  found  to  be 
low,  inoculation  is  almost  invariably  successful. 

Autogenous  vaccines  should  always  be  prepared  in  cases 
of  sycosis.  Of  three  cases  in  my  series,  two  have  reported 
well,  while  a  third  has  been  the  subject  of  relapses  from  time 
to  time.  When  a  case  comes  to  this  point,  I  think  that  in- 
oculation should  be  combined  with  whatever  other  measures 
have  been  found  expedient. 

Cases  of  impetigo  yield  so  readily  to  local  applications 
that  little  has  been  done  in  the  way  of  immunization.  I  have 
had  the  opportunity  of  observing  the  effect  of  inoculation 
upon  two  cases  only,  where  the  infection  was  limited  to  the 
beard.  Both  cases  were  greatly  improved  two  days  after 
inoculation,  and  well  at  the  end  of  one  week.  One  inocu- 
lation only  was  given  in  each  case.  A  similar  result  could 
be  obtained  by  local  treatment,  so  that  the  advantage  is 
doubtful  apart  from  the  general  protection  conveyed. 

We  now  come  to  the  last  of  the  staphylococcic  group— 
furunculosis — ranging  from  small  acute  pustules,  through 
the  thimble-sized  boil  to  the  palm-wide  carbuncle.  In  the 
majority  of  cases  of  this  group,  "stock"  vaccines  are  ad- 
missible, and  indeed,  in  a  large  number  of  cases  expedient 
for  primary  inoculations ;  in  subsequent  inoculations,  however, 
personal  vaccines  should  be  employed. 

In  these  acute  localized  staphylococcic  infections,  bacterial 
inoculation  yields  the  most  brilliant  results.  Practically  all 
cases  react  favorably. 

VOL   I. — 19 


2Qo        SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

Opportunity  to  observe  the  effect  of  tuberculin  in  the 
treatment  of  lupus  has,  in  my  experience,  been  limited  to 
two  cases:  one,  extensive  and  long-standing,  involving  prac- 
tically the  whole  of  the  face,  showed  improvement  at  first, 
but,  as  advancement  was  slow,  other  methods  of  treatment 
were  resorted  to ;  the  second,  an  acute  lesion  on  the  upper  lip, 
healed  completely  after  three  months'  treatment.  Inocula- 
tion in  the  latter  case  was  only  resorted  to  after  various  local 
applications  had  been  tried  and  the  patient  had  spent  two 
months  in  the  country. 

The  objective  and  subjective  symptoms  following  in- 
oculation are,  to  a  trained  observer,  almost  as  valuable  guides 
as  the  opsonic  findings.  Experience  teaches  one  that  ex- 
acerbations in  the  local  symptoms  are  the  harbinger  or 
accompaniment  of  a  depressed  immunity  (negative  phase). 
On  the  other  hand,  comparative  anaemia  accompanies  the 
positive  phase.  This  latter  phenomenon,  no  doubt,  accounts 
for  the  decrease  in  the  subjective  symptom  of  pain,  invariably 
admitted  in  severe  furuncular  infections.  In  old  lupus  cases, 
the  bleaching  of  the  scar  is  a  very  striking  feature.  Con- 
stitutional symptoms  are  rarely  met  with  and  should  never 
develop  if  the  dosage  is  properly  adjusted. 


BACTERIAL   INJECTIONS   IN   THE   TREATMENT 
OF  DISEASES  OF  THE  SKIN 

BY  DR.  JAY  FRANK  SCHAMBERG,  DR.  NATHANIEL  GILDERSLEEVE, 
AND  DR.  HARLAN  SHOEMAKER,  OF  PHILADELPHIA 

The  past  decade  has  been  remarkable  for  a  number  of 
discoveries  which  have  been  directly  applicable  to  the  treat- 
ment of  cutaneous  diseases.  Among  these  may  be  mentioned 
the  X-rays,  phototherapy,  radium,  and  opsonotherapy.  With 
the  advent  of  new  agencies  in  the  treatment  of  disease  there 
are  invariably  enthusiasts  whose  claims  are  extravagant. 
The  curative  virtues  of  the  treatment  are  exaggerated  and  not 
infrequently  the  newly  announced  therapy  is  viewed  in  the 
light  of  a  panacea  for  a  variety  of  ills.  On  the  other  hand, 
we  are  sure  to  find  a  body  of  men  who  are  conservative  to  the 
point  of  skepticism  or  incredulity.  They  refuse  to  believe 
until  forced  to  by  the  cold  logic  of  facts. 

The  history  of  medicine  has  exhibited  frequent  proof  of 
the  desirability  of  conservatism  among  its  votaries.  New 
treatments  have  from  time  to  time  been  loudly  heralded  as 
revolutionizing  discoveries  only  to  be  tried  and  ultimately 
consigned  to  oblivion.  On  the  other  hand,  great  men  have 
set  the  sign  of  their  disapproval  upon  new  measures  which 
have  come  to  be  recognized  as  true  and  important  advances. 

Time  is  the  important  factor  which  ultimately  assigns  to 
each  new  treatment  its  proper  place  and  value. 

It  is  premature  to  anticipate  the  critical  discernment  of 
mature  experience  by  attempting  at  the  present  time  to  deter- 
mine the  value  or  to  define  the  limitations  of  the  new  opsono- 
therapy. It  is  the  duty  of  those  who  have  had  some  experience 
with  the  new  treatment  to  place  their  observations  on  record, 
so  that  a  proper  estimate  of  its  value  may  be  arrived  at  as 

early  as  possible. 

291 


292  SIXTH  INTERNATIONAL 

Like  most  therapeutic  advances,  opsonotherapy  has  been 
developed  from  the  cumulative  researches  of  various  workers. 
Pasteur  might  be  said  to  have  laid  the  foundation  stones 
of  this  treatment.  He  was  firmly  of  the  opinion  that  in- 
fectious diseases  would  ultimately  be  controlled  by  protec- 
tive inoculations.  The  present  treatment  was  made  possible 
by  the  epoch-making  researches  of  Metchnikoff  on  phagocytosis. 
The  defensive  role  played  by  leucocytes  against  bacterial 
invasion  was  championed  by  him  against  strong  opposition. 
To  Leishman  (1902)  are  we  indebted  for  developing  a  method 
of  measuring  the  phagocytic  activity  of  leucocytes.  Wright 
and  Douglas,  in  1903,  after  painstaking  researches,  proved 
that  the  leucocytes  ingested  and  destroyed  bacteria  only 
under  the  influence  of  activating  substances  in  the  blood 
fluids.  They  furthermore  demonstrated  that  the  action  of  these 
substances  could  be  influenced  by  measures  within  our  control. 

The  bacteria  are  so  modified  by  the  blood  fluids  as  to 
render  them  ready  prey  to  the  action  of  the  phagocytic 
leucocytes.  These  substances  were  designated  "opsonins" 
from  the  Greek  opsono,  "I  prepare  food  for."  The  opsonins 
are  presumed  to  act  by  entering  into  chemical  combination 
with  bacteria  and  so  changing  them  that  they  are  readily 
ingested  and  destroyed  by  the  phagocytes. 

Through  the  beautiful  technique  elaborated  by  Leishman, 
Wright,  and  Douglas,  it  is  now  possible  to  measure  with  a 
fair  degree  of  accuracy  the  patient's  defensive  power  against 
organisms  which  are  attacking  him.  The  resisting  power 
of  the  individual,  formerly  expressed  only  in  vague  and  in- 
definite terms,  may  now  be  almost  mathematically  calculated. 

The  mere  presence  of  pathogenic  germs  does  not  produce 
disease;  so  long  as  the  defensive  machinery  of  the  body  is 
able  to  overcome  the  bacterial  attack,  the  corporeal  fortress 
remains  intact.  When  the  balance  of  power  is  upset  by  a 
weakening  of  the  defensive  agencies,  the  germs  invade  the 
system,  elaborate  poisons,  and  produce  disease. 

The  claim  to  distinction  of  the  English  researches  lies 
not  only  in  the  acquired  ability  to  estimate  the  defensive 
strength  of  the  body  fluids,  but  to  reinforce  them  by  com- 
paratively simple  means. 


DERMATOLOGICAL  CONGRESS  293 

The  bactericidal  power  of  the  blood  against  certain  specific 
organisms  may  be  raised  by  the  injection  of  a  proper  quantity 
of  a  sterilized  culture  of  those  bacteria.  There  is  at  first 
a  temporary  reduction  of  the  resisting  power,  corresponding 
to  what  has  been  called  the  "negative  phase. "  The  process, 
Wright  says,  "takes  away  temporarily  from  the  patient's 
power  of  resistance  with  a  view  of  his  receiving  back  that 
power  with  usury.  " 

There  are  a  number  of  cutaneous  diseases  due  to  the 
noxious  influence  of  micro-organisms  which  ordinarily  form 
a  part  of  the  normal  bacterial  flora  of  the  skin.  When  such 
organisms  as  the  staphylococcus  produce  a  disease  of  the 
skin  they  do  so  because  the  defensive  blood  elements  which 
commonly  safeguard  the  body  are  weakened. 

It  has  long  been  recognized  that  certain  patients  exhibit 
a  vulnerability  to  staphylococcic  invasion.  These  patients 
will  exhibit  upon  proper  examination  a  weakness  of  their 
staphylo-opsonins.  In  many  instances  it  is  possible  to  in- 
crease and  strengthen  these  substances  so  that  the  normal 
balance  of  resistance  is  re-established.  Heretofore,  we  were 
obliged  to  be  content  with  an  effort  to  kill  the  bacteria  upon 
the  skin,  an  almost  hopeless  task,  and  to  raise  the  patient's 
resisting  power  by  tonics,  foods,  and  improved  hygiene. 

Below  are  appended  brief  case  histories  of  the  patients 
treated  by  us.  The  frequency  and  dosage  of  the  inoculations 
were  in  some  cases  guided  by  a  study  of  the  opsonic  index, 
and  in  others  by  attention  to  the  clinical  appearances  alone. 
We  are  of  the  opinion  that  our  results  were  rather  better 
when  we  were  guided  by  the  former. 

In  the  majority  of  the  inoculations  autogenous  cultures, 
i.e.  cultures  from  the  patient's  own  lesions,  were  employed. 
We  feel  that  these  give  better  results  than  the  use  of  stock 
bacterial  emulsions,  although  we  have  seen  the  latter 
accomplish  decided  results. 

A  description  of  the  technique  employed  is  omitted  in  order 
to  economize  space.  In  general  we  followed  the  method  so 
carefully  detailed  by  Wright. 


294  SIXTH  INTERNATIONAL 

SYCOSIS    VULGARIS 

CASE  i.  S.  R.,  age  twenty-nine,  sycosis  of  five  months' 
duration.  Entire  bearded  region  of  face  and  neck  covered 
with  scattered  follicular  pustules.  A  few  pustules  on  right 
wrist.  Had  received  varied  local  treatment  consisting  of 
sulphur,  mercurial,  and  ichthyol  lotions  and  ointments,  and 
some  X-ray  treatment,  without  any  benefit. 

Opsonic  index  to  staphylococcus  aureus,  0.6. 

On  April  4,  1907,  received  one  hundred  and  sixty-five 
million  staphylococcus  aureus. 

On  April  9,  1907,  index  had  risen  to  0.8.  Injection  of  two 
hundred  and  thirty  million  aureus. 

On  April  16,  1907,  index  further  raised  to  i.o. 

Four  days  after  last  injection  an  indurated  mass  the  size 
of  a  goose  egg  and  very  painful  appeared  at  site  of  injection 
on  the  back.  This  looked  as  if  it  might  suppurate,  but  grad- 
ually disappeared  without  doing  so. 

An  improvement  in  the  eruption  began  a  few  days  after 
the  first  injection,  and  progressed  rapidly,  so  that  by  April 
22,  1907,  or  eighteen  days  after  the  first  injection,  the  lesions 
had  entirely  disappeared. 

It  is  now  over  five  months  since  the  patient  was  treated 
and  the  face  has  remained  entirely  well,  not  a  single  new  pus- 
tule developing.  But  two  injections  were  given.  No  other 
treatment  was  employed. 

SYCOSIS    VULGARIS 

CASE  2.  C.  F.,  age  thirty-nine.  For  two  years  patient 
has  had  boils  about  neck  and  jaw,  also  pustules  about  hair 
follicles.  At  time  of  inauguration  of  treatment  a  number  of 
pustules  were  present,  and  on  left  side  of  jaw  a  large  indurated 
linear  patch  containing  pus.  On  May  17,  1907,  received  an 
injection  of  four  hundred  million  staphylococcus  aureus  cul- 
tured from  the  patient's  lesions.  An  improvement  in  the 
condition  of  the  face  began  within  a  week.  The  improvement 
continued  and  in  about  a  month  the  infiltrated  suppurative 
patch  had  almost  disappeared.  A  few  new  pustules  developed 
on  neck. 


DERMATOLOGICAL  CONGRESS  295 

Patient  seen  August  31,  1907,  was  vastly  improved  and 
practically  free  of  eruption ;  only  a  few  small  dried-up  pustules 
visible. 

This  patient  had  pronounced  reaction  in  the  back  where 
the  injection  was  given,  which  terminated  in  an  abscess.  This 
was  the  only  patient  in  whom  such  a  condition  occurred. 

The  patient  is  now  almost  well. 

SYCOSIS  VULGARIS 

CASE  3.  A  circumscribed  sycosis  limited  to  the  upper 
lip  just  below  the  nostrils.  Duration  eleven  years.  New 
pustular  lesions  develop  every  few  days. 

Culture  taken  on  June  3,  1907,  and  five  days  later  an 
injection  of  staphylococcus  aureus  was  given.  Pustules 
began  to  dry  rapidly.  Itching  which  was  present  has  de- 
cidedly lessened.  The  first  new  pustule  developed  five  weeks 
ago.  Patient  was  seen  on  March  31,  1907,  and  said  he  had 
had  no  pustules  in  six  weeks.  The  patch  is  slightly  red  and 
scaly. 

Only  one  injection  given.  No  local  reaction  at  site  of 
injection. 

SYCOSIS  VULGARIS 

CASE  4.  H.  S. ,  age  twenty-three,  deaf  mute.  Very  severe 
sycosis  of  entire  hairy  region  of  mustache  and  beard  on  both 
sides.  Nodular  infiltrations;  eruption  markedly  red  and 
inflammatory. 

On  May  28,  1907,  injection  of  four  hundred  million  staphy- 
lococcus albus  cultured  from  the  lesions.  The  following  day 
a  new  pustular  outbreak  occurred,  and  for  some  time  after- 
wards the  eruption  was  worse  than  before  treatment. 

On  June  17,  1907,  forty  million  mixed  aureus  and  albus 
injected.  No  improvement. 

July  5,  1907,  about  eight  million  aureus  was  injected. 

July  19,  1907,  forty  million  aureus  injected. 

August  3,   1907,  fifty  million  aureus. 

August  10,  1907,  one  hundred  million  aureus. 

The  patient  was  last  seen  on  September  3,  1907,  and  now 


296  SIXTH  INTERNATIONAL 

shows  a  pronounced  improvement.  The  face  is  smoother, 
paler,  less  infiltrated,  and  shows  but  few  recent  lesions, 
Treatment  will  be  continued.  It  would  seem  that  this  pa- 
tient received  too  large  an  initial  dose,  which  resulted  in  a 
pronounced  and  prolonged  negative  phase. 

SYCOSIS    VULGARIS 

CASE  5.  S.  F.,  age  thirty-two.  Circumscribed  sycosis  of 
upper  lip  just  below  nostrils.  Duration  five  years.  New 
pustules  develop  every  day. 

On  July  19,  1907,  fifty  million  injection  of  staphylococcus 
aureus  cultured  from  lesions  was  given. 

July  23,   1907,  no  improvement. 

August  3,  1907,  ten  million  staphylococcus  albus  (auto- 
genous) injected. 

August  10,  1907,  one  hundred  million  albus  given. 

August  13,  1907.  Fissure  has  healed  and  patch  entirely 
dry.  Patient  is  now  vastly  improved  and  appears  to  be 
almost  well. 

Three  injections  given. 

SYCOSIS    VULGARIS 

CASE  6.  J.  S.,  age  twenty-three.  Discrete  pustules  and 
tubercles  in  bearded  region  of  right  side  of  neck.  Has  had 
outbreaks  of  pustules  on  body. 

April  27,  1907,  two  hundred  and  fifty  million  staphylococ- 
cus aureus  (cultured  from  lesions)  injected. 

April  29,  1907,  pustules  show  tendency  to  dry  up. 

May  3,  1907,  lesions  had  all  dried  up  and  the  patient 
appeared  to  be  getting  well.  Injection  of  four  hundred 
million  aureus. 

May  20,  1907,  another  injection  given;  four  days  later 
a  marked  relapse  occurred. 

This  patient  has  received  seven  injections  in  the  course 
of  twelve  weeks,  but  still  continues  to  have  relapses  and 
cannot  be  said  to  be  much  improved. 

SYCOSIS    VULGARIS 

CASE  7.     J.  M.,  age  twenty-seven.     Rebellious  sycosis  of 


DERMATOLOGICAL  CONGRESS  297 

lip  and  chin  of  four  years'  duration.  A  year  or  more  ago  the 
lip  was  X-rayed  and  a  greater  part  thereof  permanently 
depilated.  Where  the  hair  is  intact  pustules  still  appear. 

June  n,  1907,  injection  of  fifty  million  staphylococcus 
aureus  (not  autogenous). 

June  14,  1907.     Lesions  have  completely  dried  up. 

June  21,   1907.     A  few  new  pustules  appearing. 

June  27,  1907.  Patient  says  pustules  appear  more  sparsely 
than  before  injection. 

June  28,   1907.     About  eighty  million  aureus  injected. 

July  15,  1907.     Severe  relapse. 

July  19,  1907.  Twenty  million  albus  (autogenous)  in- 
jected. 

July  23,  1907.  No  new  lesions  since  last  injection.  Sub- 
sequently a  relapse. 

August  6,  1907.  Twenty  million  albus  (autogenous) 
injected. 

This  patient  has  had  four  bacterial  injections.  Temporary 
improvement  has  occurred,  but  the  result  thus  far  cannot 
be  said  to  be  satisfactory. 

SYCOSIS    VULGARIS 

CASE  8.  M.  F.,  age  forty,  son  of  Case  3.  Scattered 
patches  of  sycosis  on  upper  lip.  Pustules  small  and  patches 
inclined  to  be  dry  and  scaly. 

July  5,  1907.  Fifty  million  staphylococcus  albus  (not 
autogenous)  injected.  No  improvement. 

July  19,  1907.  One  hundred  million  of  a  pool  of  albus 
and  aureus  injected.  No  improvement. 

SYCOSIS    VULGARIS 

CASE  9.  S.  B.,  age  twenty-two.  Duration  of  disease 
two  years.  In  the  beard  of  right  side  of  face  a  reddened  patch 
five  inches  by  two  inches,  studded  with  numerous  papules 
and  pustules.  Has  been  under  treatment  constantly  without 
avail.  New  outbreaks  of  pustules  every  few  days. 

June  20,  1907.  Four  million  staphylococcus  albus  (auto- 
genous) injected. 


298  SIXTH  INTERNATIONAL 

June  29,   1907.     Face  looks  decidedly  better. 

July  5,  1907.     Forty  million  albus  given. 

July  19,  1907.  One  hundred  million  of  a  pool  of  albus 
and  aureus  injected. 

August  20,  1907.  One  hundred  million  (autogenous) 
aureus  given. 

Patient  shows  improvement,  but  the  result  is  thus  far 
not  as  gratifying  as  in  some  of  the  other  cases. 

CHRONIC   FURUNCULOSIS 

CASE  10.  M.  T.,  age  forty;  disease  has  lasted  many  years; 
entire  trunk  is  covered  with  scars.  At  the  present  time 
several  large  abscesses  on  the  buttocks  and  smaller  ones  on 
abdomen.  Staphylococcus  albus  found  in  culture.  Opsonic 
index  0.5. 

June  19,  1907.  Injection  of  twenty  million  albus.  Within 
a  few  days  patient  showed  improvement. 

Patient  also  had  a  suppurating  paronychia  on  thumb. 
Paroncyhia  on  thumb  almost  entirely  well. 

June  26,  1907.  Several  small  new  abscesses  around  the 
waist  line. 

June  28,   1907.     Forty  million  albus  injected. 

July  5,  1907.     Forty  million  albus  given. 

July  19,  1907.  One  hundred  million  pool  of  albus  and 
aureus  injected. 

August  3,  1907.     Ten  million  aureus  injected. 

August  5,    1907.     Three  new  furuncles  present. 

August   10,   1907.     One  hundred  million  aureus  injected. 

August  13,  1907.  Deeper  lesions  healing.  Few  super- 
ficial pustules  still  exist. 

August  20,  1907.  No  new  lesions.  Patient  decidedly 
improved. 

Patient  has  received  six  injections  and  is  now  almost 
if  not  entirely  well.  No  treatment  was  used  except  the 
evacuation  of  the  pus  in  the  abscesses. 

ACUTE    FURUNCULOSIS 

CASE  ii.  Mrs.  L.  P.,  age  twenty-five,  has  been  suffering 
from  boils  for  a  number  of  weeks. 


DERMATOLOGICAL  CONGRESS  299 

On  May  14,  1907,  an  injection  of  three  hundred  million 
aureus  was  given.  Patient  did  not  return  to  clinic;  on  in- 
quiry at  her  residence,  it  was  stated  that  she  had  recovered 
from  the  condition  from  which  she  was  suffering. 

CHRONIC   FURUNCULOSIS 

CASE  12.  Dr.  T.,  age  thirty-four.  Duration  of  disease 
two  years.  Has  not  been  free  from  boils  and  carbuncles 
for  more  than  three  to  four  weeks  throughout  the  entire 
period  mentioned.  Recently  the  furuncles  have  been  nu- 
merous. 

On  July  17,  1907,  thirty  million  staphylococcus  aureus 
was  injected.  No  new  lesions  developed  until  July  26,  1907, 
when  three  small  furuncles  appeared. 

On  August  2,  1907,  twenty-five  million  mixed  albus  and 
aureus  was  injected. 

On  August  28,  1907,  fifty  million  aureus  was  injected. 

August  31,  1907.  Three  hundred  million  aureus  and 
albus  injected. 

The  patient,  who  is  a  physician,  states  that  he  is  cerfcainly 
improved  since  the  treatment  was  instituted.  He  has  had 
four  injections  and  is  still  under  treatment. 

SEVERE  ACNE  INDURATA  ET  PUSTULOSA 

CASE  13.  N.  J.,  age  seventeen;  duration  of  disease  one 
year.  Extremely  severe  indurated  and  pustular  acne  covering 
the  entire  face. 

Opsonic  index  to  the  staphylococcus  aureus  0.5. 

April  27,  1907.  Three  hundred  million  aureus  injected. 
Within  a  few  days  a  perceptible  improvement  in  the  face  was 
noted. 

May  i,  1907.     Index  0.813. 

May  3,  1907.  Four  hundred  million  aureus  injected. 
Patient  very  much  improved. 

Five  additional  injections  have  been  since  given.  The 
patient  has,  therefore,  received  in  all,  seven  injections.  The 
face  is  greatly  improved,  the  deeper  lesions  having  in  large 
part  disappeared.  Superficial  pustules  still  appear  at  times. 


300  SIXTH  INTERNATIONAL 

No   local   or   general   treatment   used.     Patient   still   under 
treatment. 

ACNE  INDURATA  ET  PUSTULOSA 

CASE  14.  B.  A.,  female,  age  twenty-two;  duration  of 
disease  two  years.  Numerous  indurated  and  pustular  lesions 
over  face.  This  patient  has  received,  up  to  the  present  time, 
six  injections  of  the  staphylococcus.  There  has  not  been 
much  improvement. 

ACNE 

CASE  15.  M.  S.,  female,  age  twenty;  duration  of  disease 
seven  years.  Small  papulo-pustular  lesions  over  face.  Marked 
tendency  to  flushing,  which  is  increased  by  excitement  of 
any  kind. 

This  patient  has  received  four  bacterial  injections.  No 
perceptible  improvement  in  the  acne  lesions  has  taken  place, 
but  a  most  remarkable  disappearance  of  the  redness  is  noted. 
The  patient's  face  was  always  flushed  at  her  appearance  at 
the  clinic,  but  is  now  comparatively  pale.  She  states  that  the 
flushing  has  practically  ceased. 

ACNE     PAPULOSA 

CASE  1 6.  J.  M.,  age  twenty-three;  duration  of  disease 
eleven  years.  Small  papulo-pustules  scattered  over  face  and 
neck. 

Three  injections  have  been  given;  only  a  slight  improve- 
ment is  noted. 

ACNE 

CASE  17.  T.  S.,  female,  age  sixteen;  duration  of  disease 
five  months.  Profuse  eruption  of  very  small  papules  and 
pustules  over  cheeks,  chin,  and  nose. 

Three  injections  have  been  given  without  any  marked 
improvement. 

ACNE   AND   SEBACEOUS   ABSCESSES 

CASE    1 8.     Mrs.    J.    R,   age  thirty;   duration   of  disease 


DERMATOLOGICAL  CONGRESS  301 

twelve  years.  Numerous  sebaceous  abscesses  of  the  face 
varying  in  size  from  a  pea  to  a  hickory  nut.  Also  small 
pustular  lesions. 

Patient  has  had  all  sorts  of  treatment,  including  a  course 
of  X-ray  exposures.  Staphylococcus  aureus  found  in  culture. 

This  patient  received  four  injections  of  the  albus  and 
aureus  within  a  period  of  two  months.  She  is  vastly  im- 
proved, and  is  now  free  from  all  deep  lesions. 

ACNE   AND   SEBACEOUS   ABSCESSES 

CASE  19.  J.  H.,  male,  age  nineteen;  duration  of  disease 
eight  months.  Large  infiltrated  scars  beneath  which  sup- 
puration still  takes  place. 

One  injection  of  four  hundred  million  albus  and  aureus 
has  produced  a  pronounced  improvement  in  the  patient's 
condition. 

ECZEMA     VESICULOSUM    COMPLICATED    BY    A     FEW     FURUNCLES 

AND  PUSTULES 

CASE  20.  B.  P.,  female,  age  fifty-two;  duration  several 
months.  The  patient  has  had  an  erythematous  eczema  upon 
the  trunk,  with  a  pronounced  vesicular  eruption  covering 
the  patient's  face  and  arms.  Intense  itching.  Patient  later 
developed  three  or  four  furuncular  lesions  on  the  buttock  and 
hands;  the  thumb  also  became  infected  and  suppurated. 

On  May  22,  1907,  injection  of  four  hundred  million  staphy- 
lococci  was  given.  This  was  followed  by  an  immediate  dis- 
appearance of  the  pustules,  furuncles,  and  suppuration  of 
finger.  One  week  later  a  second  injection  of  Staphylococcus 
aureus  was  given.  A  paste  containing  phenol  and  calomel 
had  been  previously  used  upon  the  area  affected  with  eczema 
and  was  continued.  The  patient  experienced  a  marked 
improvement  in  her  general  health. 

The  eczema  responded  rapidly  to  treatment,  and  in  four 
weeks  had  disappeared.  A  slight  ephemeral  relapse,  char- 
acterized by  a  mild  papular  rash,  appeared  on  September 

3.  1907- 

In  this  patient  the  bacterial  injections  certainly  effected 
a  cessation  of  the  pyogenic  complications.  The  eczema 


3oa  ;     SIXTH  INTERNATIONAL 

appeared  to  be  decidedly  more  amenable  to  treatment  after 
these  injections  than  before. 

PSORIASIS 

CASE  21.  M.  M.,  male,  age  thirty-one;  duration  of  disease 
one  year.  A  considerable  number  of  coin-sized,  scaly  patches 
scattered  over  trunk.  Scales  were  cultured  from  the  surface 
of  the  lesions  and  the  staphylococcus  albus  obtained. 

On  June  9,  1907,  five  hundred  million  albus  was  injected. 
Three  days  later  there  was  an  unquestioned  tendency  of  the 
patches  to  clear  in  the  centre.  This  central  involution  con- 
tinued until  it  affected  all  of  the  patches  present.  No  other 
treatment  was  employed. 

On  June  18,  1907,  ten  million  albus  was  injected. 

July  18,  1907.  One  hundred  million  aureus  injected. 
No  improvement  appeared  to  continue  beyond  the  central 
clearing  of  the  patches. 

LUPUS   ERYTHEMATOSUS 

CASE  22.  M.  W.,  female,  colored,  age  fifty-one;  duration 
of  disease  eleven  years.  Extensive  involvement  of  the  right 
side  of  the  face  with  several  small  outlying  patches.  In  some 
areas,  great  infiltration.  Normal  pigment  lost  over  greater 
portion  of  the  affected  area.  Skin  looks  quite  whitish.  The 
condition  appears  to  have  been  aggravated  by  a  course  of 
X-ray  treatment  previously  given. 

This  patient  has  received  five  injections  of  tuberculin 
T.  R.  (P.  D.  &  Co.)  From  y^-jr  to  y^  milligram  was  in- 
jected each  time.  Some  of  the  injections  were  followed  by 
slight  febrile  reaction.  The  whitened  area  has  taken  on  a 
distinctly  more  reddish  appearance,  and  there  is  an  increased 
tendency  of  the  islets  of  normal  pigment  to  increase  in  size. 
The  patient  claims  to  have  less  itching  and  soreness  in  the 
affected  area. 

GENERAL   AND    LOCAL    REACTION 

Within  a  few  hours  after  bacterial  inoculation,  it  is  common 
for  the  patient  to  experience  an  elevation  of  temperature  of 


DERMATOLOGICAL  CONGRESS  303 

several  degrees,  accompanied  by  malaise.  The  disturbance 
seldom  lasts  longer  than  twelve  to  twenty-four  hours.  The 
larger  the  dose  given,  the  more  pronounced  is  the  constitutional 
disturbance. 

Many  patients  complain  of  some  soreness  at  the  site  of 
puncture  for  a  few  days  following  the  injection.  Occasionally 
a  circumscribed  infiltration  develops.  In  two  of  our  twenty- 
two  cases  a  decided  local  reaction  occurred.  In  one  there 
was  a  large  reddened  inflammatory  swelling  which  looked  as 
if  it  would  suppurate,  but  which  ultimately  underwent  re- 
sorption.  In  the  other  case,  a  large  abscess  developed  from 
which  four  ounces  of  pus  were  evacuated.  In  both  of  the 
cases,  the  sycosis  from  which  the  patients  were  suffering 
responded  rapidly  to  the  inoculation.  In  the  first  case,  a 
complete  cure  resulted  from  two  injections,  and  in  the  second 
a  steady  improvement  amounting  almost  to  a  cure  from  the 
one  injection.  These  observations  are  of  interest  in  con- 
nection with  the  statement  of  Wright,  that  the  greater  the 
local  reaction,  the  greater  the  amount  of  bacteriotropic  sub- 
stances formed.  He  remarks  that  in  typhoid  inoculations, 
those  cases  do  best  in  which  there  is  considerable  local  reaction. 

The  opsonic  index  taken  within  the  first  twenty-four  or 
forty-eight  hours  following  the  inoculation  will  usually  be 
found  to  be  lower  than  before.  With  this  decline,  there  is 
often  an  aggravation  of  the  cutaneous  lesions.  This  "  negative 
phase"  may  disappear  within  forty  to  seventy-two  hours, 
or  may  last  several  days  longer.  It  is  followed  by  a  rise  in 
the  index  and  an  improvement  in  the  clinical  symptoms;  this 
is  the  positive  phase. 

The  dose  of  the  bacterial  emulsion  to  be  employed  varies 
according  to  the  organism  used,  the  degree  of  depression  of 
the  index,  the  type  of  infection,  and  the  age  and  condition 
of  the  patient.  It  must  not  be  forgotten  that  there  are  in- 
dividual idiosyncrasies  in  relation  to  this  remedy,  as  well  as 
to  other  therapeutic  agents.  In  many  cases  the  dose  em- 
ployed is  too  large.  We  attribute  some  of  our  failures  or 
tardy  results  to  an  excessive  initial  dose.  It  is  best  to  start 
with  a  small  dose  and  increase.  No  absolute  rule  can  be  laid 
down  at  the  present  time  regarding  the  dosage. 


3o4  SIXTH  INTERNATIONAL 

In  general,  it  may  be  said  that  smaller  doses  should  be 
used:  when  the  index  is  very  low  than  when  moderately 
depressed;  in  acute  than  in  chronic  diseases;  in  children  and 
debilitated  individuals  than  in  adults  and  in  the  more  robust. 

In  regard  to  dosage,  Wright  says:  "The  proper  principle  of 
dosage  in  any  series  of  inoculation  is  never  to  advance  to  a 
large  dose  until  it  has  been  ascertained  that  the  dose  which  is 
being  employed  is  too  small  to  evoke  an  adequate  immunizing 
response.  A  dose  of  vaccine  may  be  adjudged  too  small  as 
soon  as  it  has  been  ascertained  that  its  inoculation  is  not 
followed  by  a  negative  phase  and  that  the  positive  phase  is 
not  well  marked,  and  is  only  of  very  short  duration." 

SUMMARY  OF  RESULTS 

Twenty-two  cases  in  all  were  treated  by  bacterial  in- 
jections. Of  these,  nine  were  cases  of  sycosis  vulgaris,  three 
furunculosis,  five  acne,  two  acne  with  sebaceous  abscesses,  one 
eczema,  one  psoriasis,  and  one  lupus  erythematosus. 

It  would  be  perhaps  misleading  to  classify  the  results  in 
a  statistical  manner.  Some  of  the  patients  have  been  under 
treatment  only  a  short  time,  and  are  continuing  to  make 
progressive  improvement.  It  is  also  possible  that  cases  now 
regarded  as  cured,  or  greatly  improved,  may  subsequently 
develop  relapses.  The  following  table,  however,  will  give 
some  idea  of  the  results  achieved. 

SYCOSIS    VULGARIS 

Cases      Results 

1  Entirely  cured. 

2  Not  improved. 

1  Greatly  improved. 

2  Slightly  improved. 

3  Almost  well. 


FURUNCULOSIS 


i        Cured. 

i       Almost  cured. 

i       Improved. 


DERMATOLOGICAL  CONGRESS  305 

ACNE 

2        Improved. 
2       Not  improved 

1  Flushing  relieved. 

ACNE  WITH  SEBACEOUS  ABSCESSES 

2  Decidedly  improved. 

ECZEMA  WITH   PYOGENIC   LESIONS 

I  Pyogenic  lesions  cured  and  eczema  rendered  amenable 
to  treatment. 

PSORIASIS 
i       Temporarily  improved. 

LUPUS  ERYTHEMATOSUS 

i       Result  not  yet  interpreted. 

Considering  the  fact  that  the  majority  of  these  cases  were 
rebellious,  of  long  standing,  and  had  resisted  approved  treat- 
ments of  all  kinds,  the  results  must  certainly  be  regarded  as 
encouraging.  It  is  impossible  at  the  present  time  to  explain 
why  one  case  of  sycosis  should  be  cured  by  one  or  two  inocu- 
lations, and  another  case  resist  the  influence  of  seven  injections. 
Future  experience  with  this  agency  may  shed  light  upon  the 
variations  in  results.  No  other  treatment,  save  possibly  the 
use  of  the  X-rays,  has  given  in  our  hands  and  in  the  hands  of 
others,  as  good  results  in  obstinate  sycosis,  as  opsonotherapy. 
These  cases  can  be  cured  by  the  X-rays,  but  it  is  often 
necessary  to  bring  about  a  permanent  atrophy  of  the  hair 
follicles  leading  to  more  or  less  disfigurement. 

In  acne,  some  workers  allege  to  have  obtained  favorable 
results  in  a  large  proportion  of  cases.  Our  results  thus  far 
are  very  indefinite.  It  is  rather  surprising  that  the  use  of 
staphylococcus  injections  should  be  curative  in  a  disease 
which  is  obviously  not  primarily  caused  by  this  organism. 
Of  course,  it  is  quite  possible  that  the  secondary  pustulation 
may  be  prevented  by  the  inoculation  of  a  culture  of  the  staphy- 
lococcus. It  would  seem  more  rational  to  employ  in  this 
disease  the  staphylococcus  in  conjunction  with  the  micro- 
bacillus,  which  is  regarded  by  some  as  an  important  etiologic 
element  in  the  causation  of  this  affection. 


VOL.    I 20 


306  SIXTH  INTERNATIONAL 

In  furunculosis  the  results  appear  to  have  been  more  con- 
stantly favorable  than  in  any  other  disease.  Heretofore,  the 
treatment  of  this  obstinate  and  distressing  condition  has 
been  limited  to  the  use  of  empiric  remedies,  nearly  all  of  which 
have  failed,  when  given  adequate  and  extensive  trial.  The 
raising  of  the  patient's  defensive  power  against  the  invasion 
of  the  staphylococcus  would  appear  to  be  the  only  scientific 
treatment  of  this  disease. 

It  is  a  pure  experiment  to  use  opsonotherapy  in  eczema. 
Nevertheless,  secondary  pustulation,  which  is  in  all  proba- 
bility a  condition  apart  from  eczema  proper,  is  so  common  that 
it  would  not  seem  unreasonable  to  expect  an  improvement 
of  the  eczema  from  the  use  of  an  agent  capable  of  restricting 
suppuration.  It  is  also  possible  that  toxins  absorbed  from 
pustular  foci  in  eczema  may  so  influence  the  individual  as  to 
lower  his  resisting  power,  and  thus  make  the  eczema  more 
rebellious  to  treatment. 

Psoriasis  could  hardly  be  expected  to  improve  under 
opsonotherapy  without  the  establishing  of  the  disease  as  a 
microbic  disorder,  and  the  discovery  of  the  parasitic  cause. 
In  the  case  reported  by  us,  the  facts  alone  are  presented 
without  any  deductions. 

If  lupus  erythematosus  is,  as  many  assert,  due  to  the  toxins 
of  the  tubercle  bacillus,  it  would  hardly  be  proper  to  inject 
such  a  toxin  with  a  view  to  bringing  about  a  favorable  result. 
The  case  reported  is  still  under  treatment,  and  does  not  admit 
at  the  present  time  of  any  definite  statements  as  to  the  result 
produced.  It  must,  of  course,  be  recognized  that  the  treat- 
ment here  is  purely  experimental. 

In  practically  all  of  the  foregoing  cases,  sole  reliance  was 
placed  upon  the  serum  treatment,  no  local  applications  or  gen- 
eral treatment  having  been  given,  except  later  in  the  rebellious 
and  unsuccessful  cases.  Such  a  course  is  necessary  in  order 
to  prevent  an  obscuration  of  the  value  of  the  treatment. 
When  the  status  of  opsonotherapy  is  once  established,  it  will 
neither  be  necessary  nor  desirable  to  rely  exclusively  upon 
bacterial  injections,  but  to  employ  them,  if  found  valuable 
in  conjunction  with  other  approved  methods  of  treatment. 
Wright  has  called  attention  to  the  fact  that  the  results  are 


PLATE  XV— To  Illustrate  Dr.  Schamberg,  Dr.  Gildersleeve,  and 
Dr.  Shoemaker's  Article. 


A 


FIG.  1. — Rebellious  Sycosis  Vulgaris  of  five  months'  duration,  resisting 
all  of  the  usual  methods  of  treatment. 


PLATE  XVI— To  Illustrate  Dr.  Schamberg.  Dr.  Gilder  sleeve,  and 
Dr.  Shoemaker's  Article. 


FIG.  2. — Patient  cured  after  two  injections  of  sterilized  staphylococcic 
emulsion.     Photograph  represents  condition  two  weeks  after 
first  photograph.     No  other  treatment  used. 
No  relapse    in  six  months. 


better  when  some  agent  which  produces  an  increased  vas- 
cularity  of  the  affected  area  is  used  in  conjunction  with 
opsonotherapy. 

By  this  means  an  opsonin-laden  lymph  or  blood  supply  is 
conveyed  to  the  affected  area.  He  counsels  such  measures 
as  radiotherapy,  Bier's  method  of  passive  hyperemia,  and 
phototherapy. 

Many  physicians  who  have  read  the  published  reports  of 
cases  treated  with  bacterial  inoculations  hesitate  to  accord 
recognition  to  opsonotherapy,  because  many  of  the  cases  sub- 
jected to  this  treatment  are  merely  improved  and  not  cured. 
A  number  of  valuable  drugs  and  therapeutic  agents  now  in 
general  use  would  likewise  fail  of  recognition  if  subjected  to 
this  standard  of  criticism. 

In  order  that  opsonotherapy  should  receive  an  established 
place  in  the  treatment  of  disease,  it  is  not  necessary  to  demon- 
strate that  it  will  alone  and  without  assistance  cure  the  disease 
for  which  it  is  used,  but  merely  that  it  will  accomplish  the 
result  aimed  at  better  than  previously  known  therapeutic 
agents. 

FURTHER  POSSIBLE  USES  OP  OPSONOTHERAPY  IN  DERMATOLOGY 

While  this  method  of  treatment  has  heretofore  been  limited 
to  lupus  vulgaris  and  circumscribed  pyogenic  affections  of 
the  skin,  it  is  not  impossible  that  it  may  be  found  of  value 
in  the  treatment  of  other  cutaneous  diseases  that  result  from 
parasitic  infection.  Thus  blastomycosis,  ringworm,  favus, 
and  actinomycosis  are  affections  in  which  this  method  of 
treatment  should  be  given  a  trial. 

Wright  has  published  cures  of  long  standing  cases  of 
furunculosis  and  sycosis  with  his  opsonic  treatment.  He 
likewise  records  some  of  his  failures. 

Varney,  of  Detroit  (Jour.  A.  M.  A.,  1907),  used  opsono- 
therapy in  twenty-five  dermatological  cases.  Most  of  these 
were  cases  of  acne,  and  the  vast  majority  are  said  to  have 
been  •  cured  by  this  treatment  alone.  Varney  says  he  has 
never  obtained  nor  seen  such  rapid  improvement  with  other 
methods  of  treatment  as  that  occurring  within  the  first  forty- 
eight  hours  after  the  first  inoculation  in  selected  cases  of  acne. 


3o8  SIXTH  INTERNATIONAL 

He  reports  five  cases  of  furunculosis  all  of  which  were 
cured  by  bacterial  injection.  Also  two  cases  of  sycosis  vulgaris, 
one  of  which  was  cured. 

Turton  and  Parker  (London  Lancet,  Oct.  27,  1906,  pages 
1130-1136),  record  thirty-four  cases,  in  which  opsonotherapy 
was  used  with  excellent  results  in  thirty.  Most  of  the  cases 
were  tuberculosis.  Among  the  cutaneous  affections  were  three 
cases  of  acne,  one  of  sycosis,  and  one  of  staphylococcic 
granuloma. 

French  (Brit.  Med.  Jour.,  February  2,  1907,  page  256), 
reports  an  infant  suffering  from  seventy-five  abscesses.  The 
case  seemed  hopeless,  but  was  rapidly  cured  by  staphylo- 
coccic injections.  He  also  reports  the  improvement  of  two 
severe  cases  of  acne  in  medical  students. 

Thorne  (Brit.  Med.  Jour.,  1907,  page  436),  reports  a  re- 
bellious case  of  furunculosis  of  three  years'  duration,  cured 
by  six  staphylococcic  injections. 

Ohlmacher  (Jour.  Amer.  Med.  Assn.,  February  16,  1907, 
page  571),  publishes  records  of  two  severe  cases  of  acne, 
greatly  improved  by  opsonotherapy,  and  notes  the  disap- 
pearance of  the  associated  oily  seborrhoea.  He  also  reports 
a  chronic  furunculosis  in  a  child  two  years  old,  cured  by  this 
treatment. 

McClintock  (Jour.  Amer.  Med.  Assn.,  1907,  page  640), 
in  discussing  Ohlmacher 's  paper,  said  he  had  treated  by 
opsonotherapy  eighteen  cases  of  cutaneous  pus  affection,  ten 
of  which  had  been  cured. 

Discussion 

DR.  A.  RAVOGLI,  of  Cincinnati,  said  he  had  been  using  the 
bacterial  vaccines  for  several  months  past  in  a  case  of  dermatitis 
herpetiformis  of  the  Duhring  type,  which  was  exceedingly  re- 
bellious and  in  which  no  culture  could  be  obtained. 

In  a  case  of  sycosis  of  five  years'  standing,  in  which  the  face 
was  covered  with  crusts  and  abscesses,  no  improvement  followed 
the  use  of  various  salves,  nor  did  the  X-rays  nor  the  Finsen  rays 
produce  any  permanent  benefit.  He  then  resorted  to  an  injection 
of  staphylococcus  pyogenes  albus,  of  one  hundred  and  fifty  millions 
of  bacteria,  per  each  injection,  and  after  about  two  hours  a  reaction 
was  obtained  with  a  distinct  temperature  elevation.  On  the  fol- 


DERMATOLOGICAL  CONGRESS  309 

lowing  day  the  tension  of  the  lesions  on  the  face  had  lessened,  the 
pustules  gradually  began  drying  up,  and  eight  days  later  the  patient 
received  a  second  injection.  Now  he  visited  the  hospital  occa- 
sionally to  receive  an  injection,  and  his  condition  was  very  satis- 
factory. The  speaker  said  he  could  confirm  what  had  been  claimed 
for  the  opsonic  method  of  treatment  in  sycosis,  and  his  personal 
experience  with  it  had  been  very  encouraging.  With  the  gonococcic 
vaccine  he  had  also  obtained  excellent  results,  and  he  recalled  the 
case  of  a  man  with  a  gonorrhoeal  arthritis  of  the  knee  who  had 
been  treated  with  aspirin  and  salicylate  of  sodium  without  result. 
The  pain  was  so  severe  that  the  patient  could  not  sleep.  He  was 
transferred  to  Dr.  Ravogli's  service,  and  was  given  an  injection 
of  gonococcic  vaccine  of  three  millions  bacteria.  After  the  very 
first  injection  he  was  able  to  sleep,  and  after  the  fifth  injection  he 
was  so  much  improved  that  he  left  the  hospital  and  returned  to 
his  work. 

DR.  E.  R.  LARNED,  of  Detroit,  said  that  there  were  two 
questions  of  the  greatest  practical  importance  which  had  not 
been  touched  upon  by  the  essayists,  which  must  be  considered  in 
regard  to  the  inoculation  with  bacterial  vaccines  in  connection  with 
the  opsonic  index. 

First:  If  it  is  true,  as  some  claim,  that  the  size  and  frequency 
of  inoculation  must  be  controlled  by  the  determination  of  the 
opsonic  index  in  every  case,  then  only  those  men  who  have  ample 
laboratory  facilities  and  are  familiar  with  the  somewhat  difficult 
technique,  could  do  the  work  satisfactorily;  but  on  the  other  hand, 
if  we  could  control  the  size  and  frequency  of  the  inoculation  by  the 
clinical  results  alone,  then  those  physicians  who  had  access  to 
bacterial  vaccines  could  apply  this  method  of  treatment,  which 
would  thus  come  within  the  reach  of  all  of  the  general  practitioners. 

The  second  question  is:  if  it  should  be  found  necessary  to  use 
autogenous  vaccines  in  each  case,  as  some  claimed,  then  only 
those  cases  could  be  treated  which  were  in  easy  reach  of  the  labora- 
tory where  these  vaccines  could  be  made,  or  cases  must  be  referred 
to  the  laboratory  workers,  who  might  be  at  some  distance  from 
the  residence  of  the  patient.  This  fact  would  place  opsonotherapy, 
in  some  instances,  beyond  the  reach  of  the  general  practitioner; 
but  if,  on  the  other  hand,  so-called  stock  vaccines  could  be  used, 
then  all  physicians  could  obtain  these  vaccines  and  treat  their 
cases. 

Dr.  Larned  also  said  that  there  was  a  third  question  growing 
out  of  these  two,  which  was,  that  if  it  should  be  found  necessary 


3io          SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

to  use  autogenous  vaccines,  the  inoculation  of  which  must  be  con- 
trolled by  the  opsonic  index,  then  it  would  be  a  long  time  be- 
fore the  problem  of  opsonotherapy  would  be  solved,  because  it  would 
limit  the  treatment  of  cases  with  bacterial  vaccines  to  those  physi- 
cians who  are  specialists  in  this  line  of  work  and  have  the  necessary 
laboratory  facilities.  But  if  it  should  be  proved  upon  adequate 
clinical  experimentation,  that  the  statements  of  some  writers 
were  well-founded,  that  it  is  sufficient  to  use  polyvalent  stock 
vaccines  and  regulate  their  dosage  by  the  clinical  findings,  then 
all  physicians  could  make  use  of  the  treatment  and  a  vastly  greater 
opportunity  for  testing  Wright's  theory  would  be  thus  provided. 
Dr.  Larned  suggested  that  these  questions  had  not  yet  been 
answered,  that  we  did  not  know  whether  it  was  absolutely  neces- 
sary to  employ  autogenous  vaccines  or  whether  stock  vaccine 
would  be  equally  efficient  and,  until  these  questions  were  solved 
beyond  all  question,  he  wished  to  express  the  opinion  that  opsono- 
therapy with  bacterial  vaccines  must  be  regarded  as  an  experimental 
problem  of  fascinating  interest  and  great  possibilities. 

DR.  STOPFORD  TAYLOR,  of  Liverpool,  said  that  in  some  of  his 
cases  of  sycosis  and  acne  he  had  derived  much  benefit  from  vaccines 
prepared  according  to  Wright,  but  the  majority  required  X-ray 
treatment  before  a  cure  resulted.  Although  he  had  used  tuber- 
culin T.  R.  largely  in  lupus  vulgaris,  he  could  not  claim  to  have 
effected  any  improvement  without  the  assistance  of  other  well 
known  methods.  The  crucial  test  was  the  disappearance  of  the 
initial  nodule,  and  this  he  had  never  seen. 


ERYTHEMA  EXUDATIVUM  MULTIFORME,  ITS 
PRESENT  SIGNIFICANCE— WITH  A  REPORT 
OF  A  CASE  OF  ERYTHEMA  CIRCINATUM 
BULLOSUM  ET  H^MORRHAGICUM  FOLLOW- 
ING A  GUNSHOT  WOUND,  APPARENTLY 
DUE  TO  STREPTOCOCCUS  INFECTION  AND 
TERMINATING  FATALLY 

BY  DR.  WILLIAM  THOMAS  CORLETT,  OF  CLEVELAND 

The  first  step  towards  grouping  the  objective  manifestations 
of  erythema  (i)  was  made  by  Hebra  (2)  in  1854.  Previous  to 
this  time  the  various  forms  delineated  by  Willan  (3)  in  1808 
were  accepted  and  treated  of  as  distinct  affections.  It  is  true 
other  observers  had  paved  the  way,  for  in  1835  Rayer  (4) 
cited  cases  collected  by  Bonnet  in  which  several  varieties  of 
erythema  were  seen  on  the  same  individual. 

Hebra  observed  that  the  various  types  of  the  erythemata, 
as  portrayed  by  Willan  and  Plenck  (5),  often  changed  from 
one  form  to  another,  and  occasionally  several  types  were  found 
co-existing.  "In  reference  to  this  point,"  he  writes,  "ex- 
perience has  taught  me  that  the  erythema  papulatum,  ery- 
thema tuberculatum,  erythema  annulare,  erythema  iris, 
erythema  gyratum  are  merely  forms  of  the  same  disease  in 
different  stages,  the  appearance  varying  according  as  the 
affection  is  undergoing  development,  or  in  a  later  period  of 
its  course,  or  subsiding.  To  this  malady  I  shall  apply  the 
name  of  erythema  multiforme"  (6). 

Erythema  multiforme  as  recognized  by  Hebra  was  a 
clearly  defined  affection  running  a  self -limited  course  in  from 
two  to  four  weeks,  although  subject  to  recurrence. 

In  1876  Lewin  (7)  collected  a  number  of  fatal  cases  of  ery- 
thema multiforme  and  maintained  that  the  conception  of  the 

311 


3i2  SIXTH  INTERNATIONAL 

affection  then  held  was  too  circumscribed,  and  that  certain 
cases  presented  the  characteristics  of  an  infection.  For 
these  he  proposed  the  name  erythema  exudativum. 

Uffelmann  (8)  also  reported  cases  to  substantiate  this 
claim. 

The  cases  thus  described  were  not  generally  recognized  as 
indubitable  instances  of  erythema  multiforme,  nor  were  the 
conclusions  derived  therefrom  generally  accepted.  Both  Ka- 
posi  (9)  and  Schwimmer  (10),  while  recognizing  a  bullous  form 
and  extending  the  boundaries  of  the  affection  as  outlined 
by  Hebra,  still  insisted  that  the  disease  adhered  to  a  definite 
type,  self-limited  in  its  course  and  terminating  in  recovery. 
The  former  proposed  the  name  erythema  polymorphe.  This 
view  has  largely  obtained  both  in  England  and  America. 
Thus,  Crocker  (n),  while  describing  in  full  the  various  forms 
erythema  multiforme  may  assume,  does  not  attribute  its 
occasional  fatality  to  the  erythema,  but  to  the  diseases  with 
which  it  is  concomitant.  The  most  recent  works  on  derma- 
tology in  this  country,  that  of  Hyde  and  Montgomery  (1904), 
Stelwagon  (1905),  and  Pusey  (1907),  while  enlarging  the 
domain  and  portraying  a  variety  of  clinical  manifestations 
under  this  caption,  still  maintain  a  clearly  defined  boundary 
and  benign  character  of  the  disease. 

Osier  (12),  studying  erythema  multiforme  from  the  view- 
point of  general  medicine,  regards  it  as  a  symptom,  not 
always  present,  of  various  diseases  of  the  internal  viscera. 

In  France  the  almost  limitless  variety  of  clinical  manifes- 
tations that  erythema  multiforme  may  assume  has  long  been 
recognized.  In  1835  Gibert  (13)  wrote  that  erythema  may  be 
symptomatic,  due  to  derangements  of  the  internal  viscera, 
and  the  following  year  Rayer  spoke  of  arthritic  fever  and 
cutaneous  hemorrhages  in  connection  with  erythema,  but  drew 
a  sharp  distinction  between  the  erythematous  and  bullous 
dermatoses. 

Besnier  and  Doyon  (14)  not  only  agree  with  Lewin  and 
Uffelmann  that  erythema  multiforme  may  pursue  a  malignant 
course,  but  further  speak  of  it  as  a  disease,  if  disease  it  may 
be  called,  that  defies  definite  classification,  an  affection  of  al- 
most infinite  variety  of  clinical  symptoms,  and  under  whose 


DERMATOLOGICAL  CONGRESS  313 

cognomen  new  forms  occur  from  time  to  time  in  the  observa- 
tion of  the  most  experienced  clinician. 

Since  the  beginning  of  the  eighteenth  century  it  has  been 
associated  with  various  diseases,  notably  purpura,  rheumatism, 
urticaria,  and  pemphigus,  until  the  clinical  line  of  demarcation 
at  times  between  them  is  not  clear.  The  cases  reported  by  Mac- 
kenzie (15),  Osier,  Fayrer  (16),  and  Wright  (17)  go  to  strengthen 
the  claim  of  this  relationship.  On  the  other  hand,  it  has 
also  occurred  in  connection  with  such  definite  affections 
as  gonorrhoea,  syphilis,  tuberculosis,  pneumonia,  enteric 
fever,  leprosy,  and  Bright's  disease;  while  more  recently 
Galloway  and  MacLeod  (18)  have  associated  it  with  lupus 
erythematosus. 

While  it  is  disconcerting  alike  to  the  student  and  to  the 
clinical  teacher,  yet  we  must  admit  that  the  definite  limitations 
of  erythema  multiforme  are  at  present  unknown.  Nor  can 
we  hope  for  a  clear  elucidation  until  the  fons  et  origo  of  the 
manifold  symptoms  which  constitute  what  we  call  erythema 
multiforme  are  better  understood. 

As  in  classification,  so  in  etiology  and  pathology,  the  great 
problem  relating  to  erythema  multiforme  has  apparently 
repeatedly  been  solved.  In  1864,  Kobner  (19),  followed  by 
Auspitz  (20),  and  Schwimmer  endeavored  to  establish  it  as  an 
angioneurosis  due  to  vasomotor  disturbances.  In  1876,  Lewin 
and  later  Molenes-Mahon  (21)  added  primary  infection  as  a 
cause,  to  which  Vidal  and  Leloir  ascribe  certain  cases.  Pto- 
maine poisoning  or  the  toxins  from  faulty  metabolism  have 
been  assigned  an  important  etiological  r61e  by  Chaisse  (22), 
Legendre  (23),  and  Galloway  (24).  Cordua  (25)  and  Luzzato 
(26)  found  micrococci  in  the  blood,  and  Haushalter  (27)  a 
streptococcus,  Leloir  (28)  both  a  diplococcus  and  a  streptococ- 
cus, while  Finger  (29)  attributed  some  cases  of  erythema 
multiforme  to  the  local  effect  of  bacteria.  Later  in  writing  of 
the  cases  of  erythema  nodosum,  purpura  rheumatica,  and  epi- 
demic zoster,  Kaposi  (30)  says: 

"  i.  Certain  typical  cases  which  occur  annually  lead  us  to 
infer  a  miasmatic  infection  or  bacterial  origin. 

"2.  Sporadic  cases  are  generally  a  reflex  effect  of  some 
anomalous  condition  of  the  internal  organs,  as  in  amenorrhoea, 


3i4  SIXTH  INTERNATIONAL 

dysmenorrhoea,  uterine  displacements,  etc.  Such  cases  are 
pure  angioneuroses. 

"3.  Some  may  be  due  to  auto-infection  with  toxic  sub- 
stances which  have  entered  the  blood  as  the  result  of  internal 
disease,  such  as  tuberculosis,  nephritis  associated  with  inflam- 
mation, suppuration  and  malassimilation "  (30). 

Besnier  and  Doyon  (31)  say :  while  there  may  be  an  infectious 
element,  it  is  subject  to  extreme  variations  and  is  influenced 
more  by  the  individual  predisposition  than  by  any  specific 
property  of  the  materies  morbi.  It  is  further  evident 
that  erythema  multiforme  may  arise  from  various  causes, 
but  whatever  the  cause  its  action  is  on  the  vasomotor  centres 
rather  than  on  the  skin  direct. 

In  cutaneous  hemorrhages  which  are  so  frequently  asso- 
ciated with  the  exudative  erythema,  Howard  (32)  has  recently 
demonstrated  in  a  number  of  cases  a  diplococcus  in  the  blood 
which  somewhat  resembles  the  pneumococcus  although  differ- 
ing from  this  organism  in  certain  details  and  corresponding 
to  that  previously  found  in  hemorrhagic  infections  by  Banti 
(33),  Babes  and  Oprescu  (34),  and  von  Dungern  (35). 

From  the  foregoing  it  is  evident  that  our  knowledge  of  the 
affection  under  consideration  is  in  a  transitional  stage,  and 
any  light  thrown  on  it  is  greatly  to  be  desired.  In  this  con- 
nection the  following  case  presents  certain  striking  features: 

J.  H.,  male,  aged  twelve  years,  with  a  negative  family 
history,  was  said  to  have  been  a  healthy,  well  developed  child 
at  birth.  At  four  months  of  age  he  had  an  abscess  in  the 
throat  of  which  the  details  are  unknown ;  at  three  years  of  age 
he  had  pneumonia,  and  at  eight  diphtheria,  in  which  antitoxin 
was  given.  After  convalescing  from  diphtheria,  an  illness 
occurred  which  the  mother  said  was  brain  fever;  she  also 
mentioned  what  might  be  malarial  fever  as  occurring  about 
this  time. 

According  to  the  mother,  the  child  has  always  been  subject 
to  febrile  attacks  lasting  a  day  or  so,  during  which  a  slight 
delirium  was  often  present.  Three  years  ago  he  visited  the 
Nose  and  Throat  Dispensary  at  Lakeside  Hospital  with  en- 
larged tonsils  and  palpable  glands  in  the  neck.  Tonsillotomy 
was  advised,  but  declined.  In  recent  years  there  have  been 


DERMATOLOGICAL  CONGRESS  315 

frequent  attacks  of  tonsillitis.  During  the  year  preceding 
the  illness  the  child  had  enjoyed  unusually  good  health. 

On  May  5,  1906,  he  was  struck  behind  the  left  ear  with  a 
shot  from  a  Flobert  rifle.  This  was  dressed  at  the  Surgical 
Dispensary  of  Charity  Hospital,  and  no  apparent  infection  fol- 
lowed. May  1 2th,  seven  days  later,  he  returned  complaining 
of  pain  in  the  ankles.  Examination  revealed  both  ankles 
swollen,  one  red  with  some  increased  local  heat,  and  a  general 
temperature  of  102°  F.  Examination  otherwise  negative. 
The  following  day  he  was  seen  by  an  outside  physician,  called 
on  account  of  an  eruption  covering  a  greater  part  of  the  body, 
and  said  by  the  physician  to  be  a  simple  urticaria.  On  the 
following  day,  May  i4th,  he  was  seen  by  Dr.  W.  H.  Merriam, 
physician  at  Charity  Hospital  Dispensary,  to  whom  I  am 
indebted  for  the  notes  of  the  case  previous  to  my  examination, 
who  reported  him  sitting  on  a  chair  unable  to  walk  on  account 
of  pain  in  the  ankles.  At  this  time  the  entire  body  was  covered 
with  an  erythematous  eruption,  and  about  the  ankles,  which 
were  slightly  swollen,  was  a  marked  degree  of  cyanosis.  On 
the  neck  were  a  few  small  bullae  containing  a  transparent, 
serous  fluid.  He  was  then  admitted  to  Charity  Hospital. 
Temperature  on  admission  was  102 °F.  Physical  examination 
was  negative  with  the  exception  of  a  slight  roughening  of  the 
systolic  tone  at  the  apex  of  the  heart.  Two  days  later,  May 
i6th,  the  case  first  came  under  the  observation  of  the  present 
writer. 

The  erythema  was  of  a  circinate  or  gyrate  variety,  with 
pinkish,  apparently  elevated  margins  enclosing  a  lighter- 
colored  central  area,  best  seen  on  the  trunk  and  adjacent 
parts  of  the  extremities.  In  some  places,  notably  on  the 
buttocks  and  lower  extremities,  the  erythema  assumed  a  darker 
hue  which  pressure  with  a  glass  slide  did  not  wholly  remove. 
There  were  also  a  few  petechiae  and  a  number  of  bullae  varying 
in  size  from  two  to  six  cm.  in  diameter,  most  abundant  on 
the  neck  and  upper  part  of  the  trunk,  although  no  region  of 
the  body  was  wholly  exempt.  (Plate  xvii.) 

The  subsequent  course  of  the  eruption  was  as  follows: 
From  day  to  day  the  erythematous  patches  gradually  became 
bullous,  first  containing  a  translucent,  serous  fluid,  which 


316  SIXTH  INTERNATIONAL 

soon  took  on  a  cloudy,  opaque  color,  and  finally  became 
hemorrhagic.  As  the  eruption  developed,  the  pain  in  the 
joints  subsided.  On  May  23d,  many  of  the  bullae  had  become 
purulent,  and  on  the  evening  preceding,  the  temperature, 
which  from  the  second  day  in  the  hospital  had  remained 
about  99°  F,  suddenly  rose  to  ioi°F.  On  this  day  the  bullae 
were  opened  to  allow  free  drainage,  and  the  patient  was  kept 
in  a  mild  antiseptic  bath.  Blood  culture  was  attempted  on 
May  23d,  but  on  attempting  to  pass  the  needle  into  the  median 
basilic  vein  it  was  found  that  the  skin  was  so  full  of  minute 
vesicles  that  it  would  be  impossible  to  obtain  a  sterile  culture. 
Cultures  from  both  the  purulent  and  hemorrhagic  bullas  gave 
pure  streptococcus  growths. 

On  the  afternoon  of  May  24th,  the  boy  developed  symp- 
toms of  failure  and  died  that  night.  There  was  some  doubt 
as  to  the  actual  cause  of  death;  it  seemed,  however,  that  it 
might  be  due  to  absorption  of  septic  material  from  the  skin 
lesions,  as  there  was  quite  a  large  area  of  denuded  surface. 

The  post-mortem  was  made  by  Dr.  J.  D.  Pilcher,  patholo- 
gist to  Charity  Hospital,  on  the  following  morning.  The  result 
of  this  examination  was  entirely  negative  with  two  exceptions 
herewith  noted.  About  the  spleen  were  numerous  old  fibrous 
adhesions  possibly  due  to  one  of  the  earlier  infections,  perhaps 
the  pneumonia.  The  gross  appearance  of  the  spleen  was  not 
at  all  that  of  a  septicaemia.  The  structure  was  more,  rather 
than  less,  dense  than  normal.  On  opening  the  stomach,  an 
area  near  the  pylorus  was  discovered  with  small  hemorrhagic 
spots.  It  was  suggested  that  such  appearance  might  have 
been  due  to  post-mortem  changes,  but  the  distinct  limitations 
of  the  area  involved  in  these  spots  rendered  this  untenable. 
Quite  close  to  the  cardiac  orifice  was  an  area  about  three 
cm.  in  diameter  which  showed  denudation  of  the  gastric 
epithelium. 

The  histological  examination  was  made  by  Dr.  Oscar 
T.  Schultz,  of  which  a  synopsis  may  be  given  as  follows : 

The  internal  organs  show  nothing  further  than  the  changes 
previously  noted,  except  that  attention  should  be  called  to 
the  presence  of  cloudy  swellings  in  the  liver  and  kidneys. 


DERMATOLOGICAL  CONGRESS  317 

Skin  Lesions.  The  epidermis  is  entirely  absent  and  the 
surface  of  the  cutis  is  covered  with  a  thin  layer  of  necrotic 
material.  The  connective  tissue  fibres  beneath  this  layer 
have  a  swollen,  opaque,  rather  hyaline  appearance.  The  blood 
vessels  of  the  cutis  are  markedly  distended,  and  the  accom- 
panying lymphatics  are  filled  with  pus  cells.  Infiltration 
by  inflammatory  cells  does  not  occur  in  the  tissue  of  the  cutis. 
The  chief  change  in  the  deeper  tissue  of  the  skin  is  limited  to  the 
blood  vessels  and  lymphatics.  This  change  is  associated  with 
a  loss  of  epidermis  and  a  superficial  necrosis  of  the  cutis.  The 
inflammation  is  of  the  exudative  type,  rather  than  of  a  pro- 
liferative  or  infiltrative  nature.  It  is  the  type  of  inflamma- 
tion that  is  often  associated  with  a  vascular  and  lymphatic 
localization  of  the  streptococcus. 

Examination  for  bacteria  shows  numerous  Gram  positive 
cocci,  usually  arranged  in  pairs,  in  the  superficial  necrotic 
zone.  Since  bacteriological  examination  of  the  fluid  of  the 
bullas  gave  pure  cultures  of  streptococci,  one  is  safe  in  assert- 
ing that  the  cocci  seen  in  sections  are  of  the  same  species. 
Occasional  cocci  are  seen  in  the  deeper  tissue  spaces.  Here 
and  there  one  can  see  a  coccus  in  a  dilated  blood  vessel,  and 
in  a  lymphatic  filled  with  pus  cells  cocci  are  fairly  numerous. 
In  a  number  of  the  distended  blood  vessels  fibrin  is  present 
and  the  vessels  are  apparently  thrombosed. 

From  the  histological  findings  there  are  two  possible 
deductions. 

1.  That  the   inflammation   of  the   skin   is   entirely   in- 
dependent of  the  gun-shot  wound,  and  is  due  to  a  primary 
infection  of  the  skin  by  the  streptococcus. 

2.  That  infection  by  the  streptococcus  occurred  by  way 
of  the  wound,  that  the  skin  inflammation  is  secondary  to  such 
an  infection,  and  that  the  case  is  one  of  generalized  infection 
with  particular  localization  of  the  organisms  in  the  skin. 

The  second  possibility  seems  much  the  more  probable  for 
the  following  reasons: 

1 .  The  involvement  of  the  skin  is  so  general  as  to  preclude 
an  infection  of  the  skin  from  without  and  a  spread  of  the  in- 
flammation in  the  skin  from  a  primary  point  of  skin  infection. 

2.  The  involvement  of  the  deeper  vessels  of  the  cutis 


3i8  SIXTH  INTERNATIONAL 

would  indicate  an  infection  of  the  skin  by  way  of  the  general 
circulation. 

3.  The  superficial  exudation  and  loss  of  epidermis  seem 
to  be  secondary  to  the  vascular  involvement. 

4.  It  is  known  that  generalized  infection,   particularly 
by  very  virulent  strains  of  streptococcus,  can  occur  without 
very  marked  changes  at  the  point  of  entry.     Death  may  result 
rapidly,  due  to  localization  of  the  organisms  at  some  point 
widely  removed  from  this  portal,  or  death  may  occur  even 
before  there  is  time  for  a  reaction  on  the  part  of  the  tissue 
elsewhere.     Examples  are  not  wanting  of  a  generalized  in- 
fection by  way  of  the  peritoneum  without  any  apparent  peri- 
toneal involvement,  and  also  infection  by  way  of  the  pregnant 
uterus. 

5.  The  gun-shot  wound  offered  an  ideal  portal  of  entry. 
For  the  reasons  given  above  it  would  seem  that  the  case 

ought  to  be  grouped  with  those  exudative  inflammations  of 
the  skin  in  which  the  skin  involvement  is  secondary  to  and 
part  of  a  generalized  infection. 

I  conceive,  the  report  continues,  the  mechanism  in  the 
production  of  the  bullae  to  be  as  follows:  Marked  exudation 
due  to  vascular  dilatation,  the  dilatation  being  caused  by  the 
action  of  the  inflammatory  agent  upon  the  blood  vessels. 
Interference  with  the  drainage  of  the  exuded  fluid,  because 
of  a  filling  up  of  lymphatics  by  inflammatory  cells  and  because 
of  thrombosis  of  some  of  the  veins.  Necrosis  of  the  epidermis 
following  the  exudation  and  the  production  of  bullae. 

In  conclusion :  While  the  case  from  a  clinical  viewpoint  is 
comparatively  infrequent,  it  is  by  no  means  unknown  as  the 
cases  reported  by  Sherwell  (36),  Osier,  Galloway  (37),  Blair 
(38),  King  Brown  (39),  and  others  affirm.  Neither  are  cases 
wanting  in  which  an  erythematous  eruption  followed  by  the 
formation  of  bullse,  hemorrhage,  and  death,  occurring  soon 
after  and  attributed  to  some  local  disturbance  or  traumatism. 
In  this  group  the  cases  of  Crocker  (40),  Welander  (41),  Nor- 
man Walker  (42),  Crawfurd  (43),  and  others  belong.  Again, 
somewhat  allied,  may  be  the  bullous  dermatoses  of  Howe  (44) 
after  vaccination,  of  Bowen  (45)  associated  with  foot-and-mouth 
disease  in  cattle,  and  the  series  of  cases,  mostly  in  butchers, 


PLATE  XVII— To  Illustrate  Dr.  W.  T.  Corlett's  Article. 


I 


DERMATOLOGICAL  CONGRESS  319 

reported  by  Fernet  (46) .  It  is  distinctive,  however,  in  owing 
its  possible  origin  to  a  gun-shot  wound,  and  the  histological 
findings  seem  to  warrant  its  being  classed  as  a  streptococcus 
infection.  Clinically  it  answers  to  what  is  now  understood  as 
erythema  exudativum  multiforme. 

BIBLIOGRAPHY 

1.  Signifying  redness,  and  employed  by  the  ancients  to  designate  all 
efflorescences  of  the  skin  not  erysipelatous. 

2.  HEBRA,  FERDINAND.     Diseases  of  the  Skin  (New  Sydenham  Soc. 
Trans.),  vol.  i.,  p.  285. 

3.  WILLAN,  ROBERT.     On  Cutaneous  Diseases,  1808,  vol.  i. 

4.  RAYER,  P.     Traiie  des  Mai.  de  la  Peau,  t.  i.,  pp.  136  et  265. 

5.  PLENCK.     Doctrin.  de  Morb.  Cutaneis,  1783. 

6.  Loc.  cit.,  pp.  285-6. 

7.  LEWIN,  G.     Ber.    klin.    Wochenschr.,    No.    23,    1876;    and    Charite 
Annalen,  No.  in,  1878. 

8.  UFFELMANN,  J.     Deutsch.  Archiv  f.  klin.  Med.,  vol.  xiv.,  1866. 

9.  KAPOSI,  M.     Hautkrankheiten,  1887,  p.  304. 

10.     SCHWIMMER,  E.     In  Ziemssen's  Handbook  of  Skin  Diseases,  1885, 

P-  370- 

n.     CROCKER,  RADCLIFFE.     Diseases  of  the  Skin,  1903. 

12.  OSLER,  WM.     Amer.  Jour,  of  Med.  Sciences,  1895,  n.  s.  ex.,  p.  629; 
1904,  cxxvii.,  p.  i. ;  and  Brit.  Jour.  Derm.,  vol.  xii.,  1900,  p.  227. 

13.  GIBERT,  C.  M.     Maladies  Speciales  de  la  Peau,  1834,  p.  89. 

14.  BESNIER-DOYON.     Mai.  de  la  Peau,    trad,  de  Kaposi  avec  notes 
et  additions,  Paris,  1891,  tome  i.,  pp.  373  et  seq. 

15.  MACKENZIE,  SIR  STEPHEN.     Brit.  Jour.  Derm.,  1896,  p.  116. 

16.  FAYRER,  J.     Brit.  Jour.   Derm.,    1896,  p.    73. 

17.  WRIGHT.     Lancet,  Jan.  18,  1869. 

18.  GALLOWAY  and  MACLEOD.     Brit.  Jour.  Derm.,  1903,  p.  81. 

19.  KOBNER.     "Klinische    u.    Experimentele    Mittheilungen,"     1864. 

20.  AUSPITZ.     "Ueber  venose  Stauung, "  Arch.  f.  Derm.  u.  Syph.,  1874. 

21.  MOLENES-MAHON.     "Contrib.    a    I'e'tude   des   mal.    infect.    d'6ry- 
theme  polymorph.  "     These  de  Paris,  1884,  No    60. 

22.  CHAISSE.     Quoted  by   Elliot   in    Morrow's  System   of   Derm,   and 
G.-U.  Dis.,  1894,  vol.  iii.,  p.  114. 

23.  LEGENDRE.     Bui.  et  Memoires  Soc.  Med.  des  Hdpitaux  de  Paris, 
No.  23,  1893. 

24.  GALLOWAY,  JAS.     Brit.  Jour.  Derm.,  1903,  vol.  xv.,  p.  243. 

25.  CORDUA.     Quoted  by  Elliot,  loc.  cit. 

26.  LUZZATO.     Rev.  din.  Milano,  1889,  No.  28,  p.  439. 

27.  HAUSHALTER.     Annales  de  Derm,  et  de  Syph.,  1887,  t.  viii.,  p.  686. 

28.  VIDAL  and  LELOIR.     Maladies  de  la  Peau,  1889,  p.  318. 

29.  FINGER,  E.     Archiv  f.  Derm.  u.  Syph.,  1893,  No.  xxv.,  p.  765. 

30.  KAPOSI,  M.     Diseases  of   the  Skin,  J.  C.  Johnston's  trans.,   New 
York,  1895,  p.  218. 

31.  BESNIER  and  DOYON.     Loc.  cit.,  vol.  i.,  p.  382  et  seq. 

32.  HOWARD,  W.  T.,  Jr.  Jour,  of  Experimental  Med.,  vol.  iv.,   No.  2, 1889. 


320  SIXTH  INTERNATIONAL 

33.  BANTI,  ~\ 

34.  BABES  and  OPRESCU>  v  Quoted  by  Howard. 

35.  VON   DUNGERN,  J 

36.  SHERWELL,  SAMUEL.     Annales  de  Derm,  et  de  Syph.,  1893,  p.  775. 

37.  GALLOWAY,  JAMES.     Brit.  Jour.  Derm.,  1903,  p.  207. 

38.  BLAIR,  L.  E.     N.  Y.  Med.  Record,  May  7,  1904,  p.  207. 

39.  BROWN,  KING.     Boston  Med.  and  Surg.  Jour.,  Feb.,  1906,  p.  126. 

40.  CROCKER,  RADCLIFFE.     Loc.  cit.,  p.  523. 

41.  WELANDER,  EDWARD.     Archiv  f.  Derm.  u.  Syph.,  Bd.  Ixxvii.,  1905. 

42.  WALKER,  NORMAN.     Brit.  Med.  Jour.,  May  18,  1901,  p.  1201. 

43.  CRAWFURD.     Lancet,  Oct.  24,  1903,  p.  1154. 

44.  HOWE,  J.  S.     Jour.  Cut.  Dis.,  June,  1905. 

45.  BOWEN,  JOHN  T.     Jour.  Cut.  Dis.,  June,  1904. 

46.  FERNET,  GEORGE.     Brit.  Jour.  Derm.,  May  and  June,  1903. 

Discussion 

DR.  OSCAR  T.  SCHULTZ,  of  Cleveland,  said  Dr.  Corlett  had 
covered  the  ground  so  thoroughly  that  there  was  very  little  to  add 
excepting  to  bring  forward  and  emphasize  the  fact  that  in  the 
case  reported,  the  general  streptococcus  infection  followed  the  in- 
fection by  way  of  the  gun-shot  wound  rather  than  that  the  skin 
was  primarily  and  independently  involved.  The  infection  came 
by  way  of  the  blood  vessels  and  the  lymphatics,  setting  up  an 
infectious  capillary  thrombosis  and  a  superficial  lymphangitis. 
In  that  process,  Dr.  Schultz  said,  he  thought  we  had  an  explana- 
tion of  the  exudative  nature  of  the  infection.  Although  the 
bullet  wound  did  not  show  any  evidences  of  infection,  it  was 
probably  by  that  route  that  the  virulent  streptococci  gained  an 
entrance  and  set  up  a  generalized  infection. 

DR.  EDWARD  H.  SHIELDS,  of  Cincinnati,  said  that  Dr.  Corlett's 
paper  had  brought  to  his  mind  a  case  which  he  saw  a  few  years 
ago.  It  was  first  seen  by  Dr.  Spiegler  of  Vienna,  who  made  no 
diagnosis,  but  Kaposi,  his  chief,  made  a  diagnosis  of  syphilis. 
In  the  course  of  three  or  four  days  he  admitted  that  he  was  mis- 
taken, and  said  he  was  unable  to  make  a  positive  diagnosis  at  the 
time.  In  the  course  of  a  week  the  erythematous  and  papular 
lesions  became  bullous  and  subsequently  hemorrhagic  and  ne- 
crotic,  and  the  patient  died  at  the  end  of  the  third  week.  The 
patient's  temperature  ranged  from  38°  to  40°  C.,  and  on  the  day  of 
his  death  it  was  40°  C.  At  the  post-mortem,  simply  an  enlarged 
spleen  was  found.  Dr.  Spiegler  had  bacteriological  tests  made, 
and  it  was  claimed  that  he  did  not  find  a  pure  streptococcus 
infection. 


DERMATOLOGICAL  CONGRESS  321 

The  case  was  described  as  a  hitherto  unknown  disease,  to  which 
Prof.  Kaposi  gave  the  name  of  erythema  papula  vesico  bullosum  et 
necroticum. 


THE  NEED  FOR  HIGHER  REQUIREMENTS  IN 
EXAMINATIONS  IN  DERMATOLOGY  AND 
SYPHILOLOGY  BY  MEDICAL  COLLEGES 
AND  LICENSING  BOARDS 

BY  DR.  WM.  F.   BREAKEY,  OF  ANN  ARBOR 

A  consideration  of  the  subject  of  the  above  title  was  under- 
taken with  the  belief  that  the  need  exists  for  higher  require- 
ments in  examinations  in  dermatology  and  syphilology,  in  our 
own  country  at  least,  and  could  be  convincingly  shown  by 
data  from  records  of  curricula  of  some  teaching  colleges  and 
examining  boards  for  license  to  practise  medicine;  and  that 
the  occasion  was  timely  for  presentation  before  an  international 
body  of  eminent  dermatologists,  whose  opinions  whether  in 
approval  or  disapproval  would  carry  weight,  with  teaching 
and  licensing  bodies  in  the  professional  world. 

I  should  further  add,  in  view  of  the  incomplete  analysis  and 
arrangement  of  facts  secured,  that  I  had  the  mistaken  notion 
that  I  could  procure  and  collate  data  with  less  labor  in  the 
time  at  my  disposal,  than  would  be  necessary  for  the  prepara- 
tion of  a  scientific  paper.  In  this  I  greatly  underestimated 
the  number  and  volume,  and  work  of  abstracting  replies 
and  catalogues  received  from  over  forty  medical  colleges, 
and  about  the  same  number  of  Examining  Boards  in  Medicine, 
in  response  to  inquiries  concerning  hours  given  to  teaching 
students,  methods  of  instruction,  etc.,  and  time  and  space, 
number  and  character  of  questions,  as  compared  with  other 
specialties  in  medicine,  given  by  examiners  to  candidates 
for  license. 

Before  sending  out  these  inquiries,  I  had  the  belief  that 
the  colleges,  with  few  exceptions,  were  the  more  delinquent 
in  the  time  given  to  instruction  in  these  subjects.  But  the 
calendars  and  schedules,  together  with  replies  from  colleges  and 
Examining  Boards,  show  that  my  belief  was  not  well  founded. 


SIXTH  INTERNATIONAL 

A  very  large  majority  of  examiners  admit  responsibility  for 
more  or  less  neglect  of  these  subjects,  most  of  the  writers  add- 
ing the  opinion  that  diseases  of  the  skin  and  syphilis  should 
receive  more  consideration.  The  reason  given  by  some  ex- 
aminers, that  the  state  law  establishing  their  Boards  does 
not  specify  these  subjects,  does  not  seem  a  sufficient  explana- 
tion, as  many  other  specialties  are  scheduled  for  examination 
as  subdivisions  of  the  general  heads  named  in  the  organic 
law;  and  some  examiners  state  that  questions  pertinent  to 
dermatology  and  syphilology  are  asked  under  general  practice 
and  general  surgery. 

It  does  not  follow  that  there  must  be  separate  heads  for 
questions  on  these  diseases.  Where  the  schedule  comprises 
but  eight  or  ten  heads,  questions  on  these  subjects,  like  other 
special  subjects,  can  be  given  under  subdivisions  of  general 
medicine  and  surgery.  Though  where  twenty  or  more  heads 
are  published  on  examination  schedules,  the  inference  would 
be  that  these  contain  all  the  special  subjects  on  which  ex- 
aminations will  be  made.  And  there  would  seem  to  be  room 
for  such  mention  of  dermatology  and  syphilology  on  official 
blanks  that  the  applicant  for  license  would  see  that  they  are 
included  in  the  examinations.  It  is  not  so  material  what  the 
reasons  are;  the  purpose  is  to  encourage  higher  and  more 
uniform  requirements.  It  is  in  no  spirit  of  hypercriticism,  but 
to  secure  facts  and  call  more  general  attention  to  conditions 
for  which  we  are  all  more  or  less  responsible. 

A  full  consideration  of  this  question  of  more  time,  it  must 
be  conceded,  may  lead  to  similar  claims  for  other  specialties, 
both  in  teaching  and  examinations,  and  logically  to  lengthened 
courses,  all  of  which  is  likely  to  come  in  the  not  very  distant 
future.  But  the  immediate  question  is,  whether  a  dispro- 
portion exists  in  the  number  and  character  of  cases  of  diseases 
of  the  skin  and  of  some  other  special  fields  of  medicine,  and 
the  implied  importance  as  shown  by  space  and  time  given 
each  in  college  curricula  and  examination  schedules. 

If  dermatology  as  a  specialty  in  medicine  was  maintained 
only  for  the  benefit  of  dermatologists,  and  they  were  merce- 
nary, they  should  not  complain.  But  as  medical  science  is 
cultivated  for  the  general  good  of  the  race,  rather  than  for 


DERMATOLOGICAL  CONGRESS  323 

physicians,  it  is  obvious  that  whatever  adds  to  more  general 
diffusion  of  all  practical  medical  knowledge,  especially 
such  as  may  be  needed  in  emergencies,  should  be  required 
by  teaching  and  examining  bodies  authorized  to  confer  de- 
grees and  to  license  practitioners. 

It  will  be  conceded  that  it  is  essential  that  the  physician 
be  able  to  diagnose  the  exanthemata,  to  protect  the  public 
by  advising  quarantine  when  needed,  and  to  avoid  panic; 
yet  to  do  this  it  is  necessary  to  differentiate  from  them  the 
various  forms  of  erythema,  dermatitis,  and  syphilis. 

The  gravity  and  often  unsuspected  presence  of  the  latter 
make  it  of  the  utmost  importance  to  the  individual,  to  the 
family,  and  to  the  public,  that  a  correct  diagnosis  be  made 
and  appropriate  treatment  carried  out.  In  view  of  the 
awakened  public  and  professional  interest  in  this  phase  of 
the  so-called  social  evil,  it  is  fitting  that  rational  scientific 
medicine  should  do  its  work,  and  receive  its  proper  recognition 
in  enlightening  the  public  upon  the  enormity  of  this  evil,  and 
in  rescuing  its  unfortunate  victims  from  the  associated  and 
but  slightly  lesser  evils  of  quackery  and  imposture. 

I  should  be  glad  to  credit  the  quotations  I  make  from  re- 
plies to  their  authors,  but  my  circular  letters  stated  that  the 
name  of  college  or  Examining  Board  would  not  be  used  without 
authority.  And,  while  the  name  of  the  writers  in  some  cases 
who  would  not  object  to  being  known,  would  lend  greater 
weight,  I  do  not  feel  at  liberty  to  vary  from  conditions  offered. 

These  extracts  from  letters,  both  from  colleges  and  Ex- 
amining Boards,  represent  opinions  of  men  covering  wide 
territory  and  in  a  position  to  estimate  the  situation  in  the 
field,  and  impress  me  as  entitled  to  much  consideration. 

I  have  not  had  time  to  secure  reports  from  enough  Euro- 
pean colleges  to  make  fair  comparison ;  the  replies  from  about 
forty  American  colleges,  including  the  most  prominent,  furnish 
some  interesting  data  and  show  that,  with  a  few  exceptions, 
a  fair  amount  of  time  is  given  to  instruction  in  diseases  of  the 
skin  and  syphilis.  Fifteen  give  instruction  in  both  third 
and  fourth  year,  lectures,  recitations,  quizzes,  and  clinics. 
Ten  give  instruction  as  part  of  combined  course  in  genito- 
urinary, venereal,  and  skin  diseases.  Four  or  five  have  no 


324  SIXTH  INTERNATIONAL 

separate  course,  teaching  dermatology  in  a  few  incidental 
lectures  with  general  medicine,  and  syphilis  with  surgery. 
Five  give  only  one  hour  a  week;  but  most  of  those  reporting 
range  from  two  to  four  hours  a  week,  and  a  few,  including 
recitations  in  sections  and  hospital  work,  count  six  hours  or 
more  for  part  of  the  term.  A  large  majority  exceed  the 
forty  hours  recommended  by  the  Association  of  American 
Colleges. 

The  following  extracts  from  letters  without  classification 
serve  to  show  the  plans  of  teaching  in  different  colleges. 

The  secretary  of  a  Canadian  Province  college  says: 

' '  We  have  no  special  course  in  dermatology  or  syphilology. 
A  special  skin  clinic  is  held  at  the  hospital  once  a  week  for 
the  final  students.  There  are  also  didactic  lectures  on  the 
subject,  but  these  are  not  extensive.  The  work  in  syphilology 
is  done  partly  in  the  course  in  surgery. " 

The  secretary  of  one  of  the  oldest  medical  colleges  in  the 
South,  which  gives  thirty-four  didactic  and  sixteen  clinical 
hours  in  dermatology  in  the  junior  year  and  nearly  an  equal 
number  to  syphilology  in  connection  with  genito-urinary 
and  venereal  diseases,  adds: 

"  I  am  personally  of  the  opinion  that  both  of  these  subjects 
are  of  great  importance  to  the  general  practitioner,  and  that 
in  the  past  an  insufficient  amount  of  time  has  been  devoted 
to  the  teaching  of  them." 

The  secretary  of  a  Pacific  coast  college  that  gives  one 
hour  a  week  in  the  junior  year  and  three  in  the  senior  year, 
says: 

"  I  believe  our  students  get  enough  work  as  to  syphilis, 
but  might  with  advantage  get  more  in  dermatology,  but  it 
seems  hard  to  find  time  for  more  in  this  line.  There  can  be 
no  doubt  as  to  the  needs  of  the  general  practitioner  for  more 
knowledge,  especially  of  dermatology.  The  average  doctor 
feels  that  he  knows  but  very  little  about  it,  and  the  only  way 
to  overcome  this,  in  my  judgment,  is  to  insist  on  more  clinical 
work  in  that  line." 

The  dean  of  a  New  England  college  writes : 

' '  We  follow  the  hours  adopted  by  the  Association  of  Amer- 
ican Colleges,  twenty  for  lectures  and  quizzes,  and  twenty 


DERMATOLOGICAL  CONGRESS  325 

for  clinical  work,  besides  time  given  to  these  subjects  in  hos- 
pital and  dispensaries.  I  believe  in  higher  requirements  in 
these  and  many  other  subjects." 

Another  New  England  college  writes: 

' '  The  importance  of  full  diagnostic  and  therapeutic  know- 
ledge of  these  subjects  cannot  be  overestimated.  We  are 
trying  to  do  as  well  as  we  can  under  our  limitations. " 

One  of  the  oldest  New  England  colleges,  which  gives  one 
thirty-fourth  of  the  required  time  of  the  junior  year  and  one 
twenty-first  of  the  required  time  of  the  senior  year  to  these  sub- 
jects, says  the  subjects  mentioned  are  "of  the  utmost  impor- 
tance to  the  general  practitioner."  He  thinks  the  number 
of  hours  devoted  to  these  branches  is  soon  to  be  increased. 

The  dean  of  an  old  college  where  both  subjects  are  taught 
in  the  senior  year,  and  constitute  about  four  per  cent,  of  the 
total  number  of  required  hours  in  the  year,  adds : 

"There  can  be  no  question  as  to  the  importance  of  these 
subjects  to  the  general  practitioner,  but  unless  the  medical 
courses  are  lengthened  to  five  years  it  will  be  difficult  to 
devote  more  time  to  these  specialties  during  the  regular 
curriculum." 

The  secretary  of  an  interior  western  college  writes : 

' '  It  seems  to  me  that  it  would  be  better  to  provide  optional 
courses  in  addition  to  the  required  work  in  a  number  of  special 
subjects." 

Another  western  college  writes: 

' '  The  general  practitioner  should  especially  acquaint 
himself  with  all  syphilitic  dermal  manifestations,  as  the 
consequence  of  an  erroneous  diagnosis  is  far-reaching." 

The  dean  of  a  long-established  college  in  a  central  state, 
that  has  taught  dermatology  nearly  thirty  years,  writes: 

' '  The  juniors  and  seniors  do  section  work  in  the  outdoor 
department  every  day  of  the  week  and  receive  one  clinical 
lecture  a  week  throughout  the  whole  course.  ...  I  believe 
dermatology  to  be  important  to  practitioners  simply  because 
it  is  necessary  to  know  it.  For  pedagogic  purposes  it  is  one 
of  the  most  valuable  departments  as  it  teaches  the  student 
to  observe." 

"Hebra  was  in  the  habit  of  saying  that  in  dermatology 


326  SIXTH  INTERNATIONAL 

the  diagnosis  should  be  made  in  the  same  manner  as  a  min- 
eralogist recognizes  a  crystal,  or  a  botanist  a  plant." 

Letter  from  a  Pacific  coast  college  in  which  dermatology 
has  been  taught  for  over  twenty  years  in  conjunction  with 
syphilology  and  genito-urinary  diseases  reads  as  follows : 

' '  A  knowledge  of  dermatology  and  syphilology  is  of 
great  importance  not  only  because  of  the  various  manifes- 
tations of  the  latter  disease,  but  also  because  of  the  minute 
distinctions  which  are  necessary  to  be  made  in  diagnosis, 
...  to  realize  the  importance  of  syphilis  in  its  social  re- 
lations, and  to  teach  students  that  it  is  not  always  or  neces- 
sarily a  disease  of  vice,  to  protect  the  innocent  offspring  as 
far  as  possible  from  its  ravages,  as  well  as  those  who  are 
already  susceptible  to  its  infection." 

Without  attempt  at  order,  I  quote  extracts  from  replies 
as  they  were  received  from  Examining  Boards.  The  secre- 
tary of  one  of  the  newer  states  writes : 

"I  have  not  at  hand  a  list  of  the  examination  questions 
in  the  past,  but  feel  safe  in  saying  that  there  have  been  but 
few  questions  asked  by  the  Board  of  this  State  at  the  examina- 
tions, upon  the  subjects  of  dermatology  and  syphilology. 
.  .  .  Your  inquiry  suggests  the  importance  of  giving  these 
subjects  more  attention  at  the  examinations,  and  I  will  send 
your  letter  to  the  other  members  of  the  Board. " 

The  secretary  of  a  far  western  state  writes: 

"Our  Board  in  its  examination  has  paid  no  particular 
attention  to  the  subjects  of  dermatology  and  syphilology. 
I  cannot  at  this  time  remember  any  questions  that  have 
been  asked  on  these  subjects." 

Here  follows  a  schedule  of  examinations  of  twenty-two 
subjects,  and  one  hundred  questions,  and  several  similar 
schedules  have  been  sent  me  in  which  diseases  of  the  skin 
and  syphilis  are  not  mentioned.  One  may  be  seen  in  Journal 
A.  M.  A.,  vol.  xlviii.,  1907,  p.  1629. 

The  secretary  of  one  of  the  northwestern  state  colleges 
writes : 

' '  I  enclose  a  copy  of  the  schedule  of  examinations.  As 
you  can  see,  we  do  not  give  the  very  important  branches  of 
the  study  of  medicine  which  you  mention  any  place." 


DERMATOLOGICAL  CONGRESS 


327 


SCHEDULE    OF   EXAMINATIONS 

Tuesday,  9  to  12  A.M.  General  Surgery,      8  questions, 

Laryngology,  2  questions, 

Ophthalmology,       3  questions, 


total  13. 


Tuesday,  2  to  4  P.M. 
Wednesday,  9  to  12  A.M. 

Anatomy, 
Pediatrics, 

8  questions, 
4  questions, 

total  12. 

Pathology, 
Bacteriology, 
Histology, 

8  questions, 
2  questions, 
2  questions, 

total  12. 

Materia  Medica 

and  Therapeutics,  7  questions, 
Practice,  8  questions, 


total  15. 


Neurology, 
Dietetics, 
Med.  Juris. 

5  questions, 
4  questions, 
3  questions,                  total  12. 

Physiology, 
Hygiene, 
Diagnosis,  Physl. 

7  questions, 
2  questions, 
3  questions,                  total  12. 

Chemistry, 
Toxicology, 
Urinalysis, 

7  questions, 
3  questions, 
2  questions,                  total  12. 

Wednesday,  2  to  4  P.M. 


Wednesday,  4  to  6  P.M. 


Thursday,  8  to  10  A.M. 


Thursday,  10  to  12  A.M. 


Total  100 

The  same  secretary  writes: 

1 '  Dr.  ,  President  of  the  State  Board,  is  the 

author  of  a  suggestive  "loo-questions  schedule.  ..."  I 
think  that  the  branches  you  mention  ought  to  have  a  place 
on  every  schedule." 

The  secretary  of  one  of  the  older  southwestern  states 
writes : 

' '  We  have  no  examination  in  the  subject  of  dermatology 
and  sy philology.  Under  the  law  we  are  limited  to  one  ex- 
amination from  each  congressional  district,  there  being  seven 
in  number;  therefore  we  are  unable  to  cover  the  entire  field 
as  well  as  might  be  done  otherwise.  The  only  questions  we 
have  upon  this  subject  is  an  occasional  one  from  one  ex- 
aminer on  practice.  The  subjects  mentioned  are  important 
and  I  wish  that  circumstances  were  so  that  we  could  be  able 
to  devote  more  time  to  them." 

The  secretary  of  a  northwestern  state  writes: 

' '  This  Board  does  not  examine  on  these  special  subjects. 


328  SIXTH  INTERNATIONAL 

...  In  my  opinion  they  are  not  sufficiently  taught,  and  from 
my  experience  as  an  examiner,  I  believe  that  a  large  per- 
centage of  our  medical  colleges  should  elevate  their  standard 
of  education;  and  I  think  a  great  deal  of  the  fault  is  in  not 
having  the  students  proficient  as  to  the  requirements  for 
admission. " 

The  secretary  of  the  Board  of  one  of  the  oldest  states 
sends  copy  of  ninety-eight  questions  under  twenty-one  heads 
— one  question  on  syphilis  and  one,  bacteriological,  on  parasitic 
diseases  of  the  skin. 

The  following  from  the  secretary  of  the  Board  of  an  old 
eastern  state  expresses  report  of  several  other  states : 

' '  Our  law  prescribes  the  subjects  in  which  applicant  for 
license  shall  be  examined,  and  the  only  opportunity  that 
there  is  of  questioning  an  applicant  on  any  of  the  collateral 
branches  is  by  the  examiner  broadening  the  scope  of  his 
examination.  I  think  it  important  for  dermatology  and 
syphilology  to  be  included  in  the  examination." 

Another  secretary  of  one  of  the  older  eastern  states, 
similarly  to  last,  writes: 

' '  Under  the  law  these  subjects  cannot  be  treated  separately, 
but  questions  under  these  topics  may  be  asked  under  one 
of  the  subheads.  .  .  .  Under  the  law  which  has  recently  been 
passed  by  our  legislature  questions  on  both  the  subjects  will 
doubtless  be  additionally  asked  under  other  subheads." 

In  one  of  the  old  southern  states  the  secretary  writes : 

"Our  Board  requires  an  examination  in  skin  and  genito- 
urinary diseases,  asking  five  out  of  one  hundred  questions 
in  this  branch.  Two  of  the  questions  are  usually  devoted 
to  genito-urinary  diseases  and  three  to  skin  diseases.  We  find 
about  two  per  cent,  of  our  applicants  fail  on  this  branch, 
while  it  assists  in  causing  failure  in  the  general  average  of 
about  six  per  cent. " 

The  secretary  of  an  old  southern  state  writes,  sending 
questions  for  past  three  examinations: 

' '  I  note  that  the  subjects  you  mention  are  not  asked 
there,  and  the  reason  of  this  is  that  we  are  not  allowed  to 
examine  in  practice.  .  .  .  Ours  is  a  peculiar  law,  but  it  is 
the  best  that  we  could  get  from  our  Legislature." 


DERMATOLOGICAL  CONGRESS  329 

From  the  secretary  of  a  large  northwestern  state: 
"As  you  will  notice  by  enclosed  schedule,  a  special  list 
of  questions  is  not  prescribed  for  dermatology  or  syphilology. 
.  .  .  Personally  I  am  of  the  opinion  that  the  time  has  arrived 
when  Examining  Boards  should  pay  more  attention  to  these 
special  subjects." 

The  secretary  of  another  state  in  the  northwest  writes, 
deprecating  the  fact  that  with  ten  papers  not  much  can  be 
done  on  special  subjects;  yet  of  half  a  dozen  lists  of  past 
examinations  in  medicine,  one  or  two  of  the  ten  questions  in 
each  list  were  well-chosen  questions  in  diseases  of  the  skin. 
Most  of  them  acute,  some  of  them  communicable  diseases. 
There  were  also  some  discriminative  questions  on  syphilis. 
The  secretary  of  one  of  the  oldest  western  states  says : 
' '  This  Board  does  not  give  examinations  in  dermatology 
and  syphilology.  .  .  .  There  is  no  time  allotted  or  questions 
required  for  either  of  these  subjects." 

In  one  of  the  largest  and  most  populous  of  western  states 
a  list  of  twenty-one  subjects  furnished  was  by  the  secretary 
on  official  blank,  in  which  is  no  mention  of  diseases  of  skin 
or  syphilis. 

From  an  old  eastern- middle  state,  secretary  writes: 
' '  Diseases  of  the  skin  and  syphilis  are  classed  by  our 
Board  with  practice  of  medicine  and  surgery.  There  are 
always  two  and  sometimes  three  questions  in  each  of  these 
subjects  asked.  .  .  .  The  practice  of  medicine  and  surgery 
are  two  subjects  that  most  of  our  applicants  fail  in.  ...  I 
believe  that  there  is  need  of  more  thorough  teaching  of  these 
subjects  by  some  of  the  medical  colleges,  if  not  by  all  of 
them." 

The  secretary  of  an  old  New  England  state  writes : 
' '  Since  the  organization  of  our  Board,  I  do  not  recall  that 
there  have  been  any  questions  asked  on  diseases  of  the  skin 
or  syphilis  at  our  examinations.     It  is  a  mistake.     There 
surely  should  be." 

The  secretary  from  an  old  southern  state  writes: 
' '  Questions   on    branches   mentioned   have    very  seldom 
formed  part  of  examinations,  probably  from  the  fact  that  we 
only  examine  in  writing." 


330 

The  secretary  of  a  northwestern  state  writes : 

"  On  dermatology  and  syphilology  we  do  not  make  a 
separate  examination.  .  .  .  We  have  been  trying  hard  for 
years  to  get  our  standard  up  where  it  should  be,  and  hope 
to  make  many  changes  in  our  law  at  the  next  session  of  the 
Legislature. " 

The  secretary  of  one  of  the  newer  mountain  states  writes: 

' '  Our  Board  of  Examiners  does  not  conduct  any  exami- 
nation on  dermatology  or  syphilology.  .  .  .  One  or  two  ques- 
tions are  sometimes  asked  on  these  subjects  under  the  head 
of  pathology  and  symptomatology.  ...  In  my  opinion 
there  is  a  woeful  lack  of  proficiency  in  the  profession  at  large 
upon  these  branches.  .  .  .  Trusting  that  time  will  bring  us 
out  of  the  present  chaotic  condition  of  medical  licensure,  I 
am,  etc." 

This  writer  presents  some  interesting  opinions  on  the 
subject  of  specialism  in  general,  that  I  regret  lack  of  space 
prevents  copying. 

The  secretary  of  a  northwestern  state  says : 

"  The  subjects  mentioned  have  been  largely  ignored  by 
our  Board,  ...  a  question  on  syphilology  occasionally  ap- 
pearing among  the  questions  on  surgery.  ...  I  think  it 
desirable  to  elevate  the  subjects  mentioned  to  the  dignity  of 
a  separate  paper." 

From  the  secretary  of  a  southern  state: 

"Our  Board  does  not  examine  in  dermatology  except  in- 
cidentally, .  .  .  nor  more  than  an  occasional  question  on 
syphilis." 

Boards  in  our  neighboring  Canadian  Provinces  so  far 
as  heard  from  have  no  special  questions,  only  as  part  of 
medicine  and  surgery. 

The  secretary  of  a  prominent  middle-northwestern  state 
writes : 

' '  Diseases  of  the  skin  and  syphilis  are  not  special  subjects 
with  our  Board  and  are  included  or  supposed  to  be  included 
in  the  questions  on  practice  of  medicine.  I  agree  with  you 
that  there  is  need  for  higher  requirements  in  board  examina- 
tions in  dermatology  and  syphilology.  At  our  next  meeting, 
in  October,  I  shall  call  the  attention  of  the  members  to  these 


DERMATOLOGICAL  CONGRESS  331 

subjects.  ...  I  am  sending  you  the  questions  since  1900; 
very  few  questions  on  dermatology  have  been  asked." 

From  one  of  the  West  India  Islands: 

"  Candidates  for  examination  as  a  rule  are  not  ac- 
quainted with  local  skin  diseases,  which  are  to  a  great  extent 
parasitic." 

Letter  from  the  Surgeon-General  of  the  United  States 
Army,  which  I  have  permission  to  publish,  states: 

"The  Army  Medical  School  is  intended  for  graduates  from 
reputable  medical  schools  who  pass  the  required  entrance 
examination  for  appointment  in  the  Medical  Corps  of  the 
Army.  ...  It  is  probable  that  of  the  ten  questions  asked 
in  practice,  not  more  than  one  relates  to  dermatology  and 
syphilis.  The  course  of  instruction  at  the  school  does  not 
include  either  dermatology  or  venereal  diseases,  except  as 
possible  sources  of  infection  under  military  hygiene." 

The  Surgeon-General  of  the  Navy  writes,  quoting  Naval 
Medical  Examining  Board: 

' '  It  has  not  been  the  custom  of  the  Naval  Medical  Ex- 
amining Board  to  give  written  questions  to  the  candidates 
before  it  in  either  syphilis  or  dermatology.  .  .  .  Examina- 
tions in  syphilis  are  conducted  orally  as  a  part  of  surgery 
and  in  dermatology  under  the  title  of  medicine.  There  are 
therefore  no  questions  on  file.  .  .  .  The  examinations  in 
both  subjects  may  be  said  to  hold  a  relatively  unimportant 
place  in  the  examination  as  a  whole,  and  even  under  the  larger 
subjects  of  which  they  are  a  part  are  given  minor  standing. 
Candidates  as  a  rule  are  inclined  to  look  upon  an  examination 
in  dermatology  as  in  eye  and  ear,  etc.,  as  an  unfair  requirement. 

' '  It  has  been  the  experience  of  this  Board  that,  generally 
speaking,  candidates  have  but  a  vague  idea  of  either  subject 
and  that  a  higher  requirement  would  be  futile,  unless  the 
questions  be  taken  up  primarily  by  the  medical  schools  and 
more  given  and  more  required  there." 

A  copy  of  extracts  from  regulations  and  instructions  in 
relation  to  the  physical  examination  of  recruits  for  enlistment 
in  the  Navy  and  Marine  Corps,  kindly  sent  with  letter,  makes 
it  apparent  that  such  examinations  could  not  be  intrusted 
to  men  who  "looked  upon  an  examination  in  dermatology 


332  SIXTH  INTERNATIONAL 

as  in  eye  and  ear,  etc.,  as  an  unfair  requirement,"  or  who  had 
but  a  vague  idea  of  either  subject. 

Syphilis  is  one  of  the  general  disqualifications  for  recruits 
in  the  Navy.  The  Surgeon-General  of  the  Public  Health 
and  Marine  Hospital  Service  writes  in  reply  to  inqtfiry  as 
to  the  extent  to  which  the  examination  for  entrance  into 
that  service  requires  a  knowledge  of  skin  diseases: 

"  The  questions  on  this  subject,  asked  on  examination,  come 
under  the  heads  of  Practice  and  Pathology  and  Bacteriology. 
.  .  .  Invariably  at  least  one  question  deals  with  this  subject, 
and  very  often  two  or  three  questions  during  the  course  of  the 
examination  have  a  direct  bearing  upon  diseases  of  the  skin, 
.  .  .  The  number  of  questions  asked  on  any  one  subject 
is  usually  four  or  five,  and  from  this  the  relative  importance 
given  to  skin  diseases  can  be  judged.  .  .  .  Among  candi- 
dates for  entrance  into  the  service  a  fair  knowledge  of  skin 
diseases  is  usually  found." 

A  copy  of  the  "  Book  of  Instruction  for  the  Medical  In- 
spection of  Immigrants,"  kindly  forwarded,  shows  the  need 
of  special  knowledge  to  determine  the  "contagious"  and 
"loathsome"  diseases  which  under  the  immigration  law  are 
"excluded  from  admission  into  the  United  States." 

The  enlarged  area  of  our  own  country,  international 
travel,  and  the  great  and  constantly  increasing  immigration 
to  our  shores,  offering  increased  opportunity  for  the  intro- 
duction of  communicable  disease  most  frequently  manifested 
in  the  skin,  make  it  very  necessary  that  immigration 
and  quarantine  examiners  be  skilled  in  diagnosis  of  dermal 
affections. 

For  similar  reasons  the  general  practitioner,  who  renders 
first  aid  in  so  many  cases,  should  have  every  facility  that 
teaching  can  supply  to  acquire  a  reasonably  good  working 
knowledge  in  the  diagnosis  and  treatment  of  at  least  the 
ordinary  diseases  of  the  skin  and  syphilis,  and  the  opportunity 
to  demonstrate  it  before  Examining  Boards. 

The  schools  teach  what  their  faculties  suppose  scientific 
medicine  demands,  and  what  the  student  should  learn,  much 
of  which  is  necessarily  elementary.  The  college  may  confer 
degrees,  but  the  law,  with  wise  intent,  has  restricted  the  au- 


DERMATOLOGICAL  CONGRESS  333 

thority  to  license  to  practise  to  Examining  Boards.  These 
Licensing  Boards  supplement  the  college.  They  determine 
in  what  the  candidate  should  be  examined,  and  what  per 
cent,  of  questions  he  should  answer  correctly,  to  pass  or  fail, 
and  practically  control  the  situation.  If  applicants  for 
license  are  lacking  in  qualifications  that  the  Examiners  believe 
necessary  for  the  safety  of  patients,  and  this  fact  appears  in 
reports,  the  colleges  interested  will  surely  try  to  prevent 
the  recurrence  of  failure  with  their  graduates. 

It  is  not  necessary  to  make  comparisons,  or  to  disparage 
other  departments  of  preparatory  work,  but  it  would  seem 
obvious  that  an  examination  to  determine  the  fitness  of  a 
candidate  to  practise  medicine  should  make  sure  of  his  ability 
to  make  practical  application  of  fundamental  teaching  re- 
ceived in  laboratory,  didactic,  and  clinical  work,  in  diagnosis 
and  treatment,  and  particularly  in  emergent  conditions  where 
it  is  important  that  a  correct  diagnosis  be  made. 

It  seems  a  rational  proposition  that  higher  requirements 
in  examinations  by  colleges  and  by  Licensing  Boards  will  go 
far  to  secure  this  desideratum. 

Discussion 

DR.  A.  RAVOGLI,  of  Cincinnati,  said  he  was  a  member  of  the 
Examining  Board  for  the  licensing  of  medical  practitioners  in  the 
State  of  Ohio,  and  in  that  State  they  had  adopted  the  minimum 
standard  given  out  by  the  American  Medical  Association.  Of  the 
four  thousand  hours  that  made  up  the  entire  four  years'  college 
curriculum,  sixty-four  hours  were  to  be  devoted  to  the  study  of 
syphilology  and  dermatology,  and  in  all  the  colleges  in  the  State 
of  Ohio  it  was  obligatory  to  devote  at  least  sixty-four  hours  to  these 
branches. 

Dr.  Ravogli  said  he  was  exceedingly  interested  in  the  progress 
of  syphilology  and  dermatology,  but  he  did  not  think  they  would 
ever  succeed  in  compelling  the  candidates  to  take  a  special  exami- 
nation in  these  branches,  because  medical  students  were  already 
overburdened.  In  the  usual  examination  course,  there  were  ninety 
questions  to  reply  to  in  the  course  of  three  days.  At  least  two  or 
three  of  these  questions  should  bear  upon  syphilis  and  diseases 
of  the  skin,  without  a  special  examination  in  these  medical  branches. 

End  of  Second  Day. 


THIRD  DAY,  WEDNESDAY,  SEPTEMBER  IITH 

CLINICAL  DEMONSTRATION  OF  CASES,  9-1 1  A.  M. 

A  Case  for  Diagnosis 

PRESENTED  BY  DR.  J.  N.  HYDE  AND  DR.  F.  H.  MONTGOMERY, 

OF  CHICAGO 

A  man,  forty-six  years  of  age,  in  good  general  health. 
In  October,  1902,  systemic  disease  with  fever,  symptoms 
pointing  to  gastro-intestinal  disturbances,  great  depression, 
and  loss  in  weight  of  fifty-two  pounds  in  three  weeks.  The 
following  January,  pustules,  papules,  and  tubercles  began  to 
appear  singly  or  in  groups,  on  different  parts  of  the  body. 
Since  that  time  he  had  never  been  entirely  free  from  cutaneous 
lesions. 

Some  of  the  nodules  and  resulting  scars  appeared  to  be 
typical  of  lupus  vulgaris ;  others  (both  active  lesions  and  scars) 
were  apparently  equally  characteristic  of  syphilis.  The 
patient  did  not  react  to  injections  of  tuberculin,  and  gave 
a  history  of  prolonged  treatment  with  mercury  and  the  iodides 
without  improvement.  No  histological  examination  permitted. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wiirttemberg,  asked  if 
tuberculin  had  been  injected  for  diagnostic  purposes. 

PROF.  ERICH  HOFFMANN,  of  Berlin,  thought  it  was  impossible  to 
make  the  diagnosis  without  further  observation.  The  case  was 
probably  one  of  tuberculosis.  He  called  attention  to  one  lesion 
which  resembled  Boeck's  multiple  benign  sarcoid  (lupoid). 

DR.  H.  HALLOPEAU,  of  Paris,  was  inclined  to  regard  the  case 
as  one  of  tuberculosis. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  advised  injections  of 
tuberculin  to  help  clear  up  the  diagnosis. 

334 


SIXTH  INTERN  AT.  DERMATOL.  CONGRESS        335 

A  Case  of  Epidermolysis  Bullosa  with  Atrophy 
PRESENTED  BY  DR.  H.  W.  STELWAGON,  OF  PHILADELPHIA 
Patient,  male,  age  twenty-seven;  disease  since  early  in- 
fancy, and  appearing  most  pronouncedly  and  constantly  on 
the  upper  back  across  the  shoulders,  elbow  regions,  knee 
regions,  sides  of  the  face,  especially  about  the  ears,  and  hands; 
atrophic  changes  in  the  finger-nails  and  finger-ends  began  in 
early  boyhood.  When  shown  before  the  Congress  the  eruptive 
phenomena  were  most  evident  on  the  upper  back,  and  to  a 
less  extent  on  the  hands;  the  nails  were  gone  and  the  finger- 
ends  were  atrophic.  Upon  the  whole,  however,  there  had 
been  a  gradual,  although  slight,  lessening  in  the  activity  of 
the  process  in  the  past  several  years.  His  general  health 
was  fairly  good.  There  was  no  record  of  a  similar  case  having 
ever  occurred  in  the  family. 

DR.  H.  HALLOPEAU,  of  Paris,  thought  the  remarkable  feature 
of  the  case  was  the  cicatrization  of  the  tissues  and  the  loss  of  the 
nails.  He  recalled  a  somewhat  similar  case  in  a  young  woman 
in  whom  the  disease  began  in  early  infancy. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  reported 
a  case  of  epidermolysis  bullosa  in  a  woman  about  thirty,  who  was 
first  seen  by  Hebra  and  subsequently  was  seen  by  various  men  in 
Paris  and  London.  She  presented  the  same  condition  of  the 
fingers  as  in  Dr.  Stelwagon's  case. 

A  Case  of  a  Peculiar  Atrophic  Eruption  distributed  over  Various  Parts  of  the 
Body,  presenting  an  Appearance  Analogous  to  Linear  Naevus,  with 

Especial  Involvement  of  the  Sebaceous  Glands 
PRESENTED  BY  DR.  WM.  T.  CORLETT,  OF  CLEVELAND 
The  patient  was  an  unmarried  woman,  thirty-six  years  old; 
a  secretary.     Her  father  had  had  some  "nervous  trouble" 
following  an  injury  from  a  fall,  and  died  twelve  years  later, 
at  the  age  of  sixty-five,  of  "spinal  disease." 

The  patient's  present  illness  began  on  the  right  side  of  the 
face  when  she  was  five  years  old,  following  scarlet  fever.  It 
gradually  extended,  being  always  sharply  defined  at  the 
median  line.  Appearing  on  the  forehead,  it  extended  over 
the  right  side  of  the  nose  and  down  over  the  malar  bone; 
thence  over  the  cheek  in  front  of  the  ear,  over  the  pomum 
Adami,  about  the  size  of  a  silver  half-dollar.  Also  a  line 


336  SIXTH  INTERNATIONAL 

extending  over  the  middle  of  the  upper  lip  in  a  vertical  di- 
rection. The  next  patch  occurred  several  years  later  over 
the  angle  of  the  left  jaw;  this  was  irregularly  triangular  in 
outline,  covering  an  area  about  the  size  of  a  silver  dollar. 
The  next  patch  appeared  on  the  lower  surface  of  the  forearm. 
The  eruption  also  formed  a  line  extending  from  the  occipital 
region,  on  the  right  side,  downward  and  forward  over  the 
right  side  of  the  neck  to  the  middle  of  the  clavicle;  thence  it 
extended  downward  and  onward,  and  was  lost  just  anterior 
to  the  head  of  the  humerus.  There  was  another  patch  over 
the  gastric  region  on  the  right  side,  extending  downward 
to  the  symphysis  pubis.  The  next  patch  appeared  two  inches 
to  the  right  of  the  sternum,  extending  about  half  an  inch 
below  the  sternal  end  of  the  clavicle,  and  about  two  inches  in 
a  vertical  direction.  The  next  lesion  on  the  lower  extremities 
began  at  the  upper  third  of  the  thigh  on  its  inner  surface, 
extending  downward  over  its  posterior  surface  to  the  calf 
and  disappearing  just  above  the  outer  malleolus.  During 
the  past  eight  months  a  new  lesion  had  appeared  on  the  left 
temple,  which  was  small  and  irregular  in  outline.  Two 
months  later  a  small  lesion  appeared  under  the  left  eye.  The 
lesions  consisted,  essentially,  of  broad,  atrophic  lines  in  which 
sebaceous  matter  was  retained  in  the  follicles.  This  could 
be  squeezed  out  in  the  form  of  a  comedo  plug.  In  places, 
pea-sized  accumulations  of  sebaceous  matter  occurred.  The 
older  lesions  presented  an  atrophic  or  naevus-like  appearance. 
The  histopathology  showed  an  atrophy  of  the  skin  with  re- 
tention of  contents  of  sebaceous  follicles  in  the  regions 
involved. 

DR.  OSCAR  T.  SCHULTZ,  of  Cleveland,  showed  a  number  of 
drawings  in  connection  with  Dr.  Corlett's  case  of  linear  naevus, 
and  gave  the  following  microscopic  findings: 

Sections  from  the  skin  showed  large,  rounded,  cyst-like  spaces 
filled  with  a  stratified,  faintly  pink-stained  material.  The  cysts  were 
lined  by  a  flattened  stratified  epithelium,  evidently  derived  from 
sebaceous  gland  epithelium.  Over  the  cysts  the  epidermis  was 
thinned  and  atrophied.  Between  them  it  was  hypertrophied.  It 
was  thicker  than  normal  and  the  interpapillary  projections  were 
rather  long  and  sometimes  branched.  The  stroma  between  the 


DERMATOLOGICAL  CONGRESS  337 

cysts  was  dense,  but  showed  no  evidence  of  active  inflammation. 
DR.  H.  RADCLIFFE-CROCKER,  of  London,  referred  to  a  very  simi- 
lar case  that  was  shown  by  Dr.  Selhorst  of  The  Hague  at  the  1896 
Congress  in  London.  There  were  many  points  of  resemblance 
between  the  two  cases.  He  thought  there  was  no  doubt  that 
the  condition  was  of  congenital  origin. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  said  that 
in  Dr.  Selhorst's  case,  which  was  referred  to  by  Dr.  Crocker,  there 
were  both  hypertrophic  and  atrophic  lesions,  while  in  Dr.  Corlett's 
case  there  was  atrophy  only. 

DR.  CORLETT,  in  closing  the  discussion,  said  he  regarded  the 
case  as  belonging  to  the  group  of  linear  naevi. 

A  Case  of  Erythema  Figuratum  Persians 
PRESENTED  BY  DR.  WM.  T.  CORLETT,  OF  CLEVELAND 

The  patient  was  a  girl  twenty  years  old,  with  a  peculiar 
gyrate  and  linear  eruption  on  various  parts  of  the  body  and 
extremities.  The  eruption  first  made  its  appearance  at  the 
age  of  eleven  years  following  scarlet  fever.  The  family 
history  threw  no  special  light  on  the  course.  Only  a  moderate 
degree  of  itching  was  at  times  complained  of.  The  general 
health  had  always  been  good. 

The  case  was  remarkable  in  that  the  new  rings  found 
within  the  old  ones  carefully  followed  their  evolution.  The 
character  of  the  eruption  had  not  undergone  any  change, 
although  individual  lesions  had  disappeared  in  the  course 
of  two  or  three  years  leaving  very  slight  atrophic  scars. 

At  the  International  Dermatological  Congress  in  London 
in  1896,  Dr.  Colcott  Fox  showed  a  case  which  bore  some  re- 
semblance to  that  shown  by  Dr.  Corlett.  In  Dr.  Fox's  case, 
however,  the  lesions  started  with  pruritic  papules  which  spread ; 
there  were  also  vesicles  noted  at  the  margin  during  one  attack. 
It  was  also  worse  in  winter.  None  of  these  features  had 
been  noted  in  the  present  case. 

DR.  OSCAR  T.  SCHULTZ,  of  Cleveland,  gave  the  following  as  the 
microscopic  findings  in  the  case. 

A  piece  of  skin  was  excised  so  as  to  include  some  of  the  healthy 
tissue,  the  erythematous  region,  and  some  of  the  healed  area.  In 
the  region  of  the  erythematous  ridge  the  small  vessels  of  the  cutis 

VOL    I. 22 


338  SIXTH  INTERNATIONAL 

were  somewhat  dilated  and  were  surrounded  by  an  increased 
number  of  lymphocytes.  In  places  there  was  a  separation  of  the 
cells  of  the  epidermis.  A  later  stage  of  this  same  process  led  to 
the  formation  of  minute  vesicles  within  the  epidermis.  In  other 
places  the  vesicles  lay  just  beneath  the  horny  layer. 

In  the  healed  area  the  epidermis  was  somewhat  thinner  than 
normal.  The  papillae  were  short  and  few.  Evidently  there  was 
a  condition  of  atrophy.  The  cutis  in  this  region  was  denser  than 
elsewhere. 

There  were  no  evidences  of  active  inflammation.  In  the 
recent  reddened  portion  of  the  lesion  the  essential  changes  were 
vascular  dilatation  and  subsequent  transudation.  This  condition 
seemed  to  be  followed  by  some  trophic  disturbance,  which  resulted 
in  moderate  atrophy  of  the  skin. 

DR.  H.  HALLOPEAU,  of  Paris,  regarded  the  case  as  one  of  chronic 
urticaria,  and  called  attention  to  the  fact  that  friction  brought 
out  the  lesions  more  clearly. 

DR.  GEORGE  HENRY  Fox,  of  New  York,  agreed  with  the  present 
diagnosis  of  erythema  perstans,  but  he  predicted  that  in  the  course 
of  the  next  few  years  a  decided  change  might  occur  in  the  appear- 
ance of  the  eruption.  Tumors  were  likely  to  form,  and  it  might 
turn  out  to  be  a  case  of  mycosis  fungoides.  The  speaker  recalled 
a  case  quite  similar  to  this  one,  with  the  same  peculiar  semi-circles 
and  which  for  several  years  was  regarded  as  an  unusual  form  of 
erythema,  but  which  eventually  developed  into  a  typical  case 
of  mycosis  fungoides. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  distinctly 
recalled  the  case  that  Dr.  Fox  had  in  mind,  but  he  could  not  agree 
with  the  statement  that  it  was  analogous  to  Dr.  Corlett's  case. 
The  latter  bore  a  closer  resemblance  to  a  case  that  had  been  re- 
ported by  Dr.  T.  Colcott  Fox  of  London.  The  case  of  mycosis 
fungoides  mentioned  by  Dr.  George  H.  Fox  had  apparently  re- 
covered after  the  use  of  some  quack  pills. 

DR.  GEORGE  HENRY  Fox,  of  New  York,  said  the  patient  he 
referred  to  took  medicine  of  some  sort  and  later  got  well  and  had 
now  remained  without  a  recurrence  for  seven  or  eight  years.  It 
was  the  only  case  of  mycosis  fungoides  he  knew  of  in  which  a 
perfect  recovery  had  taken  place. 

In  reply  to  a  question  as  to  whether  there  was  pruritus  in  his 


DERMATOLOGICAL  CONGRESS  339 

case,  Dr.  Fox  said  that  for  about  a  year  pruritus  was  a  prominent 
and  most  obstinate  feature. 

DR.  CORLETT  said  there  had  been  but  little  pruritus  in  the  case 
he  had  shown. 

DR.  DOUGLASS  W.  MONTGOMERY,  of  San  Francisco,  said  that 
when  he  saw  the  patient  referred  to  by  Dr.  Fox,  there  were  raised 
and  slightly  desquamating  lesions  on  her  body.  The  other  mem- 
bers of  her  family  were  healthy,  but  slightly  seborrhceic.  The 
patient  had  remained  well  after  the  use  of  some  purgative  pills. 

DR.  ARTHUR  WHITFIELD,  of  London,  said  that  the  microscopic 
findings  in  the  skin  in  Dr.  Corlett's  case,  as  described  by  Dr. 
Schultz,  were  not  at  all  what  one  would  expect  to  find  in  a  case 
of  mycosis  fungoides.  The  histological  appearance  of  the  lesions 
of  mycosis  fungoides  was  quite  distinct,  even  in  the  very  early 
stages  of  the  disease. 

A  Case  of  a  Marked  Bluish  Discoloration  of  the  Skin  in  a  Man  aged  Thirty- 
nine,  which  Began  at  the  Age  of  Twenty-four  or  Twenty-five  and 

had  Undergone  no  Perceptible  Change  from  Year  to  Year 
PRESENTED  BY  DR.  WM.  T.  CORLETT,  OF  CLEVELAND 
The  patient  was  not  aware  of  having  taken  any  drug, 
such  as  nitrate  of  silver,  and  had  always  enjoyed  good  health, 
excepting  when  about  nineteen  years  of  age  when  he  had 
"stomach  and  bowel  trouble"  for  which  he  took  medicine. 
Although  various  opinions  were  expressed,  the  exhibitor 
was  of  the  opinion  that  it  was  due  to  the  ingestion  of  some 
form  of  silver  taken  for  the  condition  mentioned,  sometime 
prior  to  the  appearance  of  the  discoloration. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  regarded  the 
case  as  one  of  a  form  of  morbus  ceruleus  which  had  been  observed 
in  connection  with  pigmentary  cirrhosis  of  the  liver.  The  speaker 
referred  to  a  case  of  this  discoloration  which  was  shown  by  Dr. 
Mitchell  Bruce  at  a  meeting  of  the  Dermatological  Society  in 
London,  and  subsequently  published  in  the  Atlas  of  Rare  Diseases 
of  the  Skin. 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  called  attention  to  the  fact 
that  while  the  patient  was  in  an  upright  position,  his  face  grew 
distinctly  bluer.  The  roof  of  the  mouth  also  showed  a  distinct 
bluish  discoloration. 


340  SIXTH  INTERNATIONAL 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  referred 
to  a  case  of  argyrosis  that  he  had  seen  in  an  actor  at  Mannheim 
who  had  been  taking  nitrate  of  silver  for  epilepsy. 

DR.  OSCAR  T.  SCHULTZ,  of  Cleveland,  said  that  in  the  case 
shown  by  Dr.  Corlett  he  had  failed  to  find  any  silver  or  other 
pigment  in  the  skin. 

A  Case  for  Diagnosis 

PRESENTED  BY  DR.  JAY  F.  SCHAMBERG,  OF  PHILADELPHIA 
The  patient,  aged  twenty-one  years,  exhibited  a  unilateral 
eruption  of  two  years'  duration.  The  eruption  was  seen 
upon  the  right  scapular  region  where  it  presented  itself  in 
rather  streaky  patches ;  it  then  coursed  down  the  flexor  surface 
of  the  right  arm,  forearm,  and  hand.  Upon  the  hand  the 
eruption  involved  the  inside  of  the  thumb  and  the  radial 
side  of  the  index  finger.  The  eruption  consisted  of  scaly 
patches  from  pin-head  to  pea-size  in  the  beginning,  but 
which  later  coalesced  and  formed  larger  patches,  which  were 
prone  to  take  on  a  linear  form.  The  individual  lesion  and  the 
scaling  were  indistinguishable  from  that  of  psoriasis.  Vigorous 
treatment  with  chrysarobin  had  produced  no  effect  upon  the 
disease.  The  case  was  presented  for  diagnosis,  the  presenter 
taking  the  view  that  the  eruption  belonged  to  the  category 
of  naevus  unius  lateris,  with  lesions  of  a  psoriasiform  character. 

DR.  JOSEPH  ZEISLER,  of  Chicago,  said  the  case  shown  by  Dr. 
Schamberg  was  one  of  unusual  interest,  first,  as  regarded  the  char- 
acter of  the  lesions,  and  second,  in  their  distribution.  The  dis- 
tribution was  zosteriform,  while  in  character  the  lesions  were 
psoriatic.  In  the  character  of  the  eruption,  he  failed  to  see  any 
resemblance  to  lichen  planus,  and  he  would  regard  the  case  as  one 
of  psoriasis  zosteriformis. 

DR.  BOLESLAW  LAPOWSKI,  of  New  York,  referred  to  a  somewhat 
analogous  case  which  was  seen  by  Dr.  P.  A.  Morrow  at  the  New 
York  Hospital  Dispensary  and  reported  under  the  name  of  naevus. 

DR.  PRINCE  A.  MORROW,  of  New  York,  said  the  case  shown  by 
Dr.  Schamberg  was  very  similar  in  the  distribution  of  the  lesions 
to  that  in  two  cases  which  he  had  under  his  observation  a  number 
of  years  ago  at  the  New  York  Hospital,  which  were  regarded  as 
examples  of  naevus  unius  lateris.  In  one,  where  the  lesions  oc- 


DERM ATO LOGICAL  CONGRESS  341 

curred  on  the  forearm,  palm,  and  fingers,  there  was  an  extraordinary 
degree  of  epidermal  proliferation,  almost  as  abundant  as  one  saw 
in  psoriasis.  In  the  other  case  the  lesions  were  situated  on  the 
posterior  aspect  of  the  shoulders  and  running  down  the  arm;  they 
exhibited  a  peculiar  annular  configuration  as  well  as  this  remarkable 
epidermal  proliferation.  Both  of  these  cases  might  easily  have 
been  mistaken  for  psoriasis,  but  their  history  and  the  absence  of 
any  indications  of  psoriasis  proved  them  to  be  cases  of  naevus, 
and  both  were  published  and  illustrated  under  that  title. 

In  the  case  shown  by  Dr.  Shamberg,  the  speaker  said,  the  dis- 
tribution of  the  lesions  and  their  duration  would  seem  to  exclude 
psoriasis. 

A  Case  of  Leukoplakia  Buccalis  in  a  Negro 
PRESENTED  BY  DR.  HOWARD  Fox,  OF  NEW  YORK 

Patient,  aet.  fifty-two;  married;  U.  S.;  Porter. 

There  was  no  history  of  syphilis.  Patient  had  taken  a 
moderate  amount  of  liquor  regularly  all  his  life.  Formerly 
he  was  a  confirmed  pipe  smoker.  Pepper  and  spiced  foods 
have  always  made  his  mouth  sore.  There  was  no  digestive 
trouble ;  he  suffered  a  good  deal  from  bad  teeth.  The  patches 
had  existed,  patient  thought,  about  five  or  six  years.  They 
were  firm,  grayish,  adherent,  bilateral,  and  extended  from  the 
angle  of  the  mouth,  posteriorly  in  a  direction  parallel  with  the 
teeth.  A  year  ago  a  "cold  sore"  appeared  on  his  lip.  Seven 
months  ago  when  seen  for  the  first  time,  there  was  a  suspicious 
looking  warty  growth  on  the  lower  lip.  A  "V  "-shaped  piece 
of  the  lip  was  excised  and  the  glands  removed. 

A  Case  of  Idiopathic  Multiple  Hemorrhagic  Sarcoma  (Kaposi) 
PRESENTED  BY  DR.  M.  B.  HARTZELL,  OF  PHILADELPHIA 
Dr.  Hartzell  exhibited  a  man,  sixty-nine  years  old,  with 
an  affection  of  the  legs  presenting  the  following  features: 
On  the  dorsum  of  the  left  foot  and  the  anterior  surface  of  the 
leg  were  numerous  round,  oval,  and  irregularly-shaped, 
slightly  elevated,  very  dark-brown  and  slate-colored,  for  the 
most  part  smooth,  but  in  places  slightly  scaly,  firm  patches. 
On  the  calf  were  many  pea-  to  hazel-nut-sized  confluent, 
firm  nodules  similar  in  color  to  the  patches  on  the  anterior 
surface  of  the  leg,  forming  a  large  uneven  patch  covering  the 
entire  calf.  Over  the  outer  malleolus  was  a  single  nut-sized 


342  SIXTH  INTERNATIONAL 

tumor  with  a  thick  pedicle.  Upon  the  right  leg  were  a  number 
of  smooth,  flat  patches  similar  to  those  already  described. 
The  left  leg  was  markedly  swollen,  being  several  inches  larger 
in  circumference  than  the  right.  The  duration  of  the  disease 
was  fourteen  years. 

A  Case  of  Keratosis  Follicularis  or  Darier's  Disease:  Psorospermosis 

Follicularis 

PRESENTED  BY  DR.  H.  W.  STELWAGON,  OF  PHILADELPHIA 
Patient,  male,  aged  forty,  of  good  health  and  family  record- 
Disease  began  fifteen  years  previously,  and  up  to  several 
years  ago,  steadily  increased  in  extent,  involving  a  large 
part  of  the  entire  surface,  being  most  marked  on  trunk  an- 
teriorly and  posteriorly  especially  toward  the  middle  line; 
also  quite  markedly  about  the  elbow  and  knee  regions,  hands, 
feet,  and  face.  For  the  past  several  years  under  exposure 
to  the  Roentgen  rays  there  had  been  some  improvement, 
and  the  activity  of  the  process  had  been  somewhat  variable. 
There  had  existed  for  some  time  and  was  still  present  an 
associated  seborrhceic  condition  of  face,  scalp,  and  hands. 
Family  history  was  good;  no  record  of  a  similar  disease. 

I 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  said  that  in  a  case  of  kera- 
tosis  follicttlaris  which  recently  came  under  his  observation,  one  of 
the  most  remarkable  features  was  the  improvement  that  occurred 
in  cold  weather  and  the  aggravation  of  the  symptoms  in  the  summer. 

An    Unusually    Extensive    Folliculitis    and    Perif olliculitis ;    its    Connection 

with  the  So-called  Tuberculides 
PRESENTED  BY  DR.  WILLIAM  B.  TRIMBLE,  OF  NEW  YORK 

J.  L.,  born  in  the  United  States,  of  Scotch  parentage, 
forty-six  years  of  age,  a  lumberman.  His  mother  died  at 
seventy- two  from  "some  bronchial  trouble. "  The  father,  who 
was  a  hard  drinker,  died  at  fifty-five  "from  an  operation." 
There  was  a  history  of  a  skin  disease  in  the  father,  limited  to 
the  buttocks,  which  the  man  thought  was  the  same  as  his  own. 
The  patient  did  not  remember  having  any  of  the  diseases  of 
childhood,  his  only  illness  being  an  attack  of  pneumonia  six 
years  ago,  from  which  he  made  a  quick  and  uneventful 
recovery. 

The  disease  began  in  his  eighth  year  and  seemed  to  have 


DERMATOLOGICAL  CONGRESS  343 

a  peculiar  predilection  for  those  places  where  there  was  any 
pressure  or  friction.  It  appeared  first  on  the  buttocks,  ap- 
parently from  horseback  riding;  it  occurred  in  exacerbations, 
ten  to  fifteen  lesions  in  different  stages  of  development  being 
present  at  the  same  time;  a  period  of  quiescence  then  inter- 
vened, only  to  be  followed  by  a  fresh  outbreak  of  the  malady. 
The  lesion  itself  would  begin  as  a  subcutaneous  nodule, 
movable  under  the  skin,  painless,  and  could  be  felt  before  it 
became  visible.  The  size  varied  from  a  small  pea  to  that  of 
a  hazel-nut ;  in  from  seven  to  ten  days  the  nodule  would  reach 
its  height,  the  usual  size  being  that  of  a  pea;  it  would  then 
remain  stationary  for  about  two  weeks,  during  which  time 
it  would  take  on  a  slight  rose  color,  becoming  very  slightly 
yellowish  in  the  centre.  At  this  stage  the  lesions  were  mildly 
tender  on  pressure.  Rupture  would  then  take  place  (at 
about  the  end  of  the  third  week),  sometimes  by  one  opening 
and  sometimes  by  several,  from  which  would  exude  a  small 
amount  of  slightly  sticky,  sanguinolent  substance,  about  the 
consistence  of  cream.  This  would  continue  for  a  few  days 
when  the  discharge  would  dry  into  a  crust,  which  would  adhere 
for  about  a  fortnight,  finally  dropping  off,  to  leave  a  pigmented 
scar.  The  whole  process  from  the  beginning  of  the  nodule 
to  the  resolution  of  the  exudate  and  scar  formation,  would 
take  from  six  to  eight  weeks.  Rarely  some  of  the  tumors 
would  remain  dormant  for  months,  finally  undergoing  resolu- 
tion without  suppuration.  In  those  localities  where  the 
lesions  were  numerous  and  in  close  proximity,  coalescence 
would  frequently  occur. 

Histo-Pathology. — The  lesion  at  height  of  development 
consisted  of  a  much  dilated  follicle,  with  partially  destroyed 
walls  and  a  dense  intra-  and  peri-follicular  infiltration,  com- 
posed of  polynuclear  and  plasma  cells,  the  polynuclear 
predominating. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  regarded  the  eruption 
on  the  body  as  acne,  and  that  on  the  scalp  as  a  pustular  folliculitis. 

A  Case  of  Multiple  Rodent  Ulcer 

PRESENTED  BY  DR.  T.  CASPAR  GILCHRIST,  OF  BALTIMORE 
A  man,  aged  sixty-three,  with  a  large  ulcerative  epitheli- 


344  SIXTH  INTERNATIONAL 

oma,  almost  covering  the  right  shoulder  blade.  There  were 
nineteen  other  lesions  scattered  over  the  body,  face,  scalp,  and 
upper  extremities.  A  majority  of  the  lesions  were  about 
2-3  cm.  in  diameter  and  were  of  a  dull  red  color,  flat,  with 
well-defined  rather  firm  edges,  dry  and  slightly  scaly.  On 
the  face  and  scalp  there  were  thirteen  lesions.  The  duration 
of  the  whole  trouble  was  twenty  years.  Excised  portions 
from  different  lesions  showed  on  section  typical  malignant 
overgrowth  of  epithelioma  or  rather  of  rodent  ulcer.  There 
was  no  glandular  involvement.  The  patient's  health  had 
begun  to  be  undermined  during  the  last  year  only. 

A  Case  for  Diagnosis 

PRESENTED  BY  DR.  T.  CASPAR  GILCHRIST,  OF  BALTIMORE 
A  negro  child,  aged  five  years,  showing  a  well  marked 
eruption,  which  was  ichthyosis  vulgaris.  The  case  was  shown 
because  the  disease  was  so  rare  in  the  negro  race.  There 
was  no  history  of  heredity.  The  child  was  quite  healthy 
otherwise. 

A  Case  of  Leprosy — Mixed  Form 

PRESENTED  BY  DR.  CHARLES  T.  DADE,  OF  NEW  YORK 
A  young  woman,  twenty-eight  years  old,  native  of  Bar- 
badoes,  married,  two  children.  She  had  been  in  this  country 
but  five  months  and  said  when  she  came  here  last  April  her 
face  was  free.  This  case  came  under  the  observation  of  the 
demonstrator  only  the  day  before  presentation,  having  been 
reported  to  the  Board  of  Health  as  a  case  of  small-pox,  and  it 
was  through  the  courtesy  of  Dr.  S.  Dana  Hubbard  of  the  Health 
Board  that  Dr.  Dade  presented  it.  If  the  woman's  story  was 
true  the  development  was  very  rapid,  for  the  face  showed 
numerous  nodular  lesions  over  the  cheeks,  forehead,  and  chin 
and  presented  a  very  typical  appearance.  Over  the  arms  and 
body,  besides  nodules,  were  macules  from  an  inch  to  two  inches 
in  diameter,  round  and  oval,  brownish  in  color,  and  slightly 
scaly.  Anaesthesia  in  these  was  not  complete.  These  macules 
were  the  only  lesions  she  noticed  up  to  the  time  she  came  to 
this  country  last  spring.  She  had  been  treated  with  X-Rays 
but  said  without  benefit  as  the  nodules  were  increasing. 

DR.  H.  HALLOPEAU,  of  Paris,  regarded  the  case  as  one  of  leprosy. 


DERMATOLOGICAL  CONGRESS  345 

In  connection  with  the  treatment,  he  suggested  the  use  of  atoxyl, 
an  arsenic  preparation,  from  which  he  had  seen  excellent  results. 

A  Case  of  Lupoid  Sycosis  with  Bleb  Formation 
PRESENTED  BY  DR.  JAY  F.  SCHAMBERG,  OF  PHILADELPHIA 
The  patient,  a  man  aged  sixty-seven,  developed  a  sycosis 
in  1886.  Since  that  period  he  had  suffered  persistently  from 
the  disease,  involving  the  bearded  region  of  the  sides  of  the 
face.  About  1895  *ne  affection  changed  its  character  from 
an  ordinary  rebellious  sycosis  and  took  on  the  appearance 
of  a  lupoid  sycosis.  At  the  present  time  there  were  extensive 
scarring  and  atrophy  involving  the  entire  cheeks  from  the 
zygoma  to  the  border  of  the  jaw.  The  skin  was  whitish  and 
atrophic,  and  velvety  to  the  finger  passed  over  the  surface. 
There  was  complete  absence  of  hair  over  the  affected  region. 
A  remarkable  feature  of  the  disease  was  the  occurrence, 
chiefly  upon  the  spreading  border,  but  also  elsewhere,  of 
flat  blebs.  These  appeared  every  few  days  and  had  been 
developing  for  almost  a  period  of  ten  years.  The  patient 
in  addition  had  an  essential  shrinking  of  the  conjunctives  in 
marked  degree.  Microscopic  study  of  a  section  of  the  skin 
showed  complete  degeneration  and  atrophy  of  the  hair  follicles 
and  sebaceous  glands  and  their  substitution  by  fibrous  tissue. 

A  Case  of  Lupus  Erythematosus  of  Twelve  Years'  Duration  in  a  Colored 

Woman 

PRESENTED  BY  DR.  JAY  F.  SCHAMBERG,  OF  PHILADELPHIA 
This  patient  had  suffered  from  the  disease  which  she 
exhibited  for  twelve  years.  There  was  a  large  patch  covering 
the  greater  part  of  the  right  side  of  the  face  and  neck.  Over 
this  area  there  was  almost  complete  loss  of  normal  pigment 
of  the  skin,  the  patch  being  a  dead  white  color  save  for  islets 
of  pigmentation  here  and  there,  and  a  certain  degree  of  redness. 
The  border  was  slightly  raised  and  infiltrated.  The  skin  over 
certain  areas  of  the  patch  exhibited  a  considerable  degree 
of  thickening.  A  small  superficial  patch  was  present  under 
the  right  eye  and  one  also  upon  the  tip  of  the  nose.  This  pa- 
tient was  subjected  to  X-ray  treatment  in  another  city  with 
a  considerable  aggravation  of  the  disease,  the  patch  spreading 
much  beyond  its  former  limits.  She  was  now  receiving 
injections  of  tuberculin,  T.  R.,  with  apparent  benefit. 


346         SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

A^Case  of  Lupus  Vulgaris  of  Many  Years'  Standing  Practically  Cured  with 

the  X-Ray 

PRESENTED  BY  DR.  JAY  F.  SCHAMBERG,  OF  PHILADELPHIA 
A  young  woman,  aged  thirty-two  years,  developed  eight 
years  previously  a  lupus  vulgaris  which  ran  an  extremely 
rapid  course  for  this  disease.  The  cheeks,  nose,  upper  lip, 
and  sides  of  the  face  were  extensively  involved.  The  usual 
treatments  were  employed  without  benefit.  During  the  past 
three  years  the  patient  had  received  in  the  neighborhood  of  two 
hundred  X-ray  treatments,  with  the  result  that  she  was  now 
practically  cured.  One  or  two  pinhead-sized  nodules  remained 
upon  the  ear  and  one  or  two  more  were  scattered  elsewhere. 
The  cosmetic  result  was  quite  as  good  as  that  secured  by  the 
Finsen  light,  save  that  there  was  a  moderate  amount  of 
telangiectasis  in  the  scar  tissue. 


THE  REGULAR  SESSION  OF  THE  CONGRESS  WAS  CALLED  TO  ORDER 

AT  ii  A.M. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  and 
DR.  H.  HALLOPEAU,  of  Paris,  Vice-Presidents,  in  the  Chair. 


DIE   HAUTBLASTOMYKOSE  (DERMATITIS  BLAS- 

TOMYCETICA) 

VON  PRIVATDOCENT  DR.  MORIZ  OPPENHEIM,  WIEN 

Ausderk.k..Universitatsklinik  fur  Syphilidologie  und  Dermatologie  in  Wien 
(Vorstand  Prof.  Dr.  Ernst  Finger) 

Die  Tatsache,  dass  Sprosspilze  (Blastomyzeten,  Hefe- 
pilze)  pathogen  sein  konnen,  ist  noch  nicht  lange  bekannt. 
Zuerst  wurde  deren  Pathogenitat  fiir  Tiere  einwandfrei  be- 
wiesen;  einerseits  durch  Tierkrankheiten,  bei  denen  als  Erre- 
ger  Sprosspilze  gefunden  ;wurden,  anderseits  durch  das 
Experiment,  indem  es  gelang,  durch  Injektion  verschiedener 
Hefearten  Krankheiten  bei  Tieren  zu  erzeugen.  So  hat 
Metchnikoff  im  Jahre  1884  bei  erkrankten  Daphnien  einen 
Blastomyzeten  beschrieben,  den  er  Monospora  bicuspidata 
nannte,  deren  Sporen  die  Darmwand  durchbohren,  ins  Blut 
gelangen  und  durch  Allgemeininfektion  das  Tier  toten ;  Kultur 
gelang  nicht. 

Rivolta  fand  bei  einer  rotzahnlichen  endemischen  Krank- 
heit  der  Pferde,  bei  der  sogenannten  Lymphangitis  epizootica 
(1883)  stark  lichtbrechende  Korperchen  im  Eiter,  die  er 
"Cryptococcus  farcinimosus  Rivoltae"  nannte,  dessen  Kultur 
erst  1895  Fermi  und  Aruch  gelang,  die  auch  die  Hefennatur 
des  Mikro-organismus  feststellen  konnten. 

Bei  einer  ahnlichen  Krankheit  der  Pferde  und  Kinder  in 
Japan  konnte  Tokishige  eine  Hefen-  resp.  Oidienart  nachweisen, 

347 


348  SIXTH  INTERNATIONAL 

deren  Kulturen  fur  Pferde  pathogen  waren;  in  Russland  war 
es  Tartakowsky,  der  bei  dem  "afrikanischen  Rotz"  der 
Pferde  ahnliche  Mikro-organismen  auffand. 

Ferran,  Memmo,  Sirleo  und  Maffucci,  Corselli  und  Frisco, 
etc.,  fanden  bei  verschiedenen  Tieren  in  den  verschiedensten 
Organen  Blastomyzeten.  Sanfelice  stellte  die  Taubenpocken 
als  Resultat  einer  Blastomyzeteninfektion  hin. 

Der  Erste,  der  experimentell  Hefen  Tieren  injizierte, 
war  Claude  Bernard.  Er  spritzte  (1848)  Hunden  Bierhefe 
in  die  Venen  bei  Gelegenheit  seiner  Zuckeruntersuchungen ; 
die  Hunde  gingen  ein.  Er  meinte  auch,  dass  Hefen  in  die 
Gallenblase  gelangen  konnen.  Diese  Tatsache  ist  uns  his- 
torisch  interessant,  steht  aber  mit  unserer  Frage  in  keinem 
direkten  Zusammenhang.  Grohe  (1869),  Popoff  (1872)  ver- 
wendeten  zu  ihren  Impfungen  unreines  Material,  so  dass  ihre 
Resultate  nicht  einwandfrei  sind.  Neumayer  (1891)  und 
Mosler,  Raum  (1891)  und  Hueppe  (1892)  injizierten  Hefen 
mit  positivem  Erfolg.  Das  grosste  Verdienst  in  bezug  auf 
die  experimentelle  Tierblastomykose  haben  Sanfelice,  der 
aus  Fruchtsaften  seinen  Saccharomyces  neoformans  zuchtete 
(1895),  und  Lydia  Rabin owitsch,  die  unter  40  Hefestammen 
verschiedenster  Herkunft  acht  tierpathogene  fand.  Weitere 
Versuche  in  dieser  Hinsicht  stellten  an  Casagrandi,  Nesc- 
zadimenko,  Klein,  Busse  und  in  letzter  Zeit  Cohn,  Buschke 
und  Sternberg.  Aus  alien  diesen  Untersuchungen  geht  zur 
Gewissheit  hervor,  dass  die  Hefen  fiir  Tiere  insoweit  pathogen 
sind,  als  sie  Entzundung,  Eiterung  und  pyamische  Infektion 
hervorrufen  konnen. 

Wie  verhalt  es  sich  nun  mit  der  Pathogenitdt  der  Sprosspilze 
beim  Menschen  ?  Wir  konnen  der  Literatur  nach  vier  Arten  des 
Vorkommens  von  Sprosspilzen  beim  Menschen  unterscheiden : 

1.  Hefepilze  kommen  als  unschadliche  Schmarotzer  auf 
der  Haut  und  auf  Schleimhauten  vor. 

2.  Hefepilze  erzeugen  Oberflachenerkrankungen  der  Haut 
und  Schleimhaute. 

3.  Sprosspilze  sind  die  Ursache  maligner  Neubildungen. 

4.  Sprosspilze  wandern  von  der  Oberflache  ins  Gewebe 
ein,  erzeugen  hier  einerseits  Abszessbildung,  anderseits  Granu- 
lationsgewebe  mit  Neigung  zum  Zerfall  oder  zur  Bindege- 


DERMATOLOGICAL  CONGRESS  349 

websneubildung  und  verursachen  auch  durch  Eindringen  in 
die  Blutbahn  Allgemeininfektionen. 

Was  Punkt  i  betrifft,  so  ist  es  bekannt,  dass  auf  der  Haut 
und  den  Schleimhauten,  im  Stuhl,  im  Urin,  im  Magen-  und 
Darmkanal,  kurz  fast  in  alien  Gegenden  des  Korpers  und  in 
alien  Sekreten  und  Exkreten  hefeahnliche  Gebilde  gefunden 
wurden.  Dies  ist  nichts  Wunderbares,  da  ja  Sprosspilze 
ubiquitar  vorkommen. 

Ad  2 .  Hier  besteht  die  grosse  Schwierigkeit  zu  entscheiden, 
ob  die  Hefen  im  ursachlichen  Zusammenhang  mit  der  Ober- 
flachenerkrankung  stehen  oder  ob  sie  sekundar  eingewandert 
sind.  Zu  dieser  Kategorie  gehort  die  am  langsten  bekannte 
Erkrankung,  der  Soor,  hervorgerufen  durch  Oidium  albicans. 
Wir  rechnen  namlich,  dem  Vorgange  Buschkes  folgend,  die 
Oidium-arten,  die  sich  von  den  echten  Hefen  nur  durch 
starkere  Faden-  und  Lufthyphenbildung  unterscheiden,  zu 
den  Sprosspilzen.  Die  Stellung  der  Sprosspilze  selbst  ist  ja 
noch  nicht  genau  prazisiert,  indem  die  einen  fur  die  Sprosspilze 
oder  Blastomyzeten  eine  Sonderstellung  beanspruchen  (Han- 
sen),  die  anderen  sie  als  Entwicklungsstadien  der  Schim- 
melpilze  (Hyphomyzeten,  Brefeld)  ansehen,  wofur  die  Oidien 
einen  Beweis  abgeben.  Es  muss  das  deshalb  hier  erwahnt  wer- 
den,  weil  die  amerikanischen  Autoren,  namentlich  Ricketts, 
den  Namen  Oidiummykose  fur  ihre  Krankheitsfalle  einfuhren 
wollen.  Dies  ist  jedoch  nur  geeignet,  die  Verwirrung,  die  in  der 
Frage  der  Sprosspilzerkrankungen  herrscht,  zu  erhohen.  Wir 
wollen  auch  hierin  dem  Beispiele  Buschkes,  der  ja  grosse  Ver- 
dienste  in  dieser  Frage  hat,  folgen  und  vorlaufig  alle  durch 
Sprosspilze  oder  ahnliche  Pilze  beim  Menschen  hervorgerufenen 
Erkrankungen  mit  dem  Sammelnamen  Blastomykose  bezeich- 
nen.  Fur  den  Soor  und  seine  verwandtan  Arten  ist  es  nun 
durch  zahlreiche  Arbeiten  festgestellt,  dass  er  pathogen  fur 
Schleimhaute  ist  (Bernard,  Zenker,  Schmal,  Grawitz,  Parrott, 
Klemperer,  etc.) ,  aber  auch  ins  Innere  des  Korpers  eindringen 
kann.  Nicht  so  sicher  ist  fur  die  echten  Hefen  bewiesen, 
obwohl  zahlreiche  Autoren  sie  bei  Oberflachenerkrankungen, 
wie  Angina,  Tonsillitis,  Gastroenteritis,  Vaginitis,  Pharyn- 
gitis, etc.,  nachgewiesen  haben. 

Was   den   ursachlichen    Zusammenhang   der   Entstehung 


3So  SIXTH  INTERNATIONAL 

maligner  Geschwiilste  mit  dem  Vorhandensein  von  Blasto- 
myzeten  betrifft  (Punkt  3),  so  haben  die  iiberaus  zahlreichen 
Untersuchungen  der  letzten  Jahrzehnte  zu  keinem  positiven 
Resultat  gefuhrt.  Die  Mehrzahl  der  Autoren  spricht  sich 
dagegen  axis,  doch  wollen  gewichtige  Forscher,  wie  z.  B. 
Busse,  die  Sache  noch  nicht  als  abgeschlossen  betrachten 
und  ermuntern  zu  neuen  Versuchen. 

Die  vierte  Frage:  Konnen  Hefen  im  Gewebe  des  Menschen 
pathologische  Veranderungen  hervorrufen?  wurde  durch  drei 
fast  gleichzeitig  erfolgte  Beobachtungen  beantwortet.  Diese 
drei  Beobachtungen  zeigen  uns  auch  gleichzeitig  die  ver- 
schiedenen  Formen  der  Hefeerkrankungen  des  Menschen.  Es 
waren  dies  die  Beobachtungen  von  Busse-Buschke,  Gilchrist 
und  Curtis. 

Der  Fall  Busse-Buschke  (Greifswalder  mediz.  Verein, 
Juni  1894)  betraf  eine  31  jahrige  Frau,  bei  der  vor  einigen 
Jahren  an  Stirn,  Nacken  und  Gesicht  rundliche,  scharf  kon- 
turierte  Geschwure  mit  unterminierten  Randern,  zah  glasigem 
Sekret  entstanden.  Ausserdem  zeigten  sich  akneartige,  blau- 
rotliche  Knotchen  mit  gleichem  Sekret;  die  Geschwure  ver- 
grosserten  sich  von  Linsen-  bis  zu  5-Pfennigstuckgrosse.  Es 
traten  hinzu  Knochenherde  in  der  Tibia,  in  deren  Sekret 
Busse  als  Erster  die  aufgefundenen  Parasiten  als  Hefen 
deutete  und  an  einer  Rippe;  unter  Entkraftung  erfolgte  der 
Tod.  Bei  der  Obduktion  fanden  sich  Knoten  in  der  Lunge, 
Niere  und  Milz.  Histologisch  zeigte  die  Hautaffektion  (ebenso 
wie  die  ubrigen  Herde)  riesenzellenhaltige  Infiltrate  mit 
zentralem  Zerfall,  ausserdem  im  Epithel  Wucherungsvor- 
gange.  In  den  Infiltraten,  Riesenzellen,  zwischen  und  in  den 
Epithelien  doppelt  konturierte  Hefen  von  charakteristischen 
Eigenschaften.  Kultur  und  Tierexperiment  positiv. 

In  den  Geschwuren  der  Haut  wies  Buschke  zuerst  die 
Hefennatur  der  Parasiten  nach,  fruher  als  Gilchrist  der  kul- 
turelle  Beweis  der  Blastomyzetennatur  seiner  Parasiten 
gegliickt  war,  obwohl  Buschke  selbst  ebenso  wie  Gilchrist  die 
Parasiten  zuerst  fur  Protozoen  hielt. 

Der  Fall  Gilchrist,  der  unter  dem  Titel  "Protozoic  (coccid- 
ioidal)  Infection  of  the  Skin"  gemeinsam  mit  Rixford  pub- 
liziert  wurde  (im  Mai  1894  zeigte  Gilchrist  in  der  "American 


DERMATOLOGICAL  CONGRESS  351 

Dermatological  Association"  Schnitte  einer  besonderen  Haut- 
affektion),  ist  kurz  geschildert  folgender:  70  jahriger  Farmer 
von  den  Azoren,  Beginn  vor  n  Jahren  mit  ovalen  Knotchen 
im  Nacken,  dann  an  den  Augenbrauen,  weiterhin  Entstehung 
papillarer  Wucherungen  mit  eitriger  Sekretion,  sowie  Ge- 
schwiire,  die  sich  auf  Nase,  Lippe,  Wangen  und  Handrucken 
ausdehnten.  Nach  langem  Stationarbleiben  des  Prozesses 
traten  spater  Driisenschwellungen,  Somnolenz,  Schwache  und 
Husten  hinzu  und  nach  Auftreten  von  Abszessen  im  Hoden 
und  linken  Bein  starb  der  Patient.  Bei  der  Obduktion 
zeigten  sich  tuberkelahnliche  Knoten  in  Lungen,  Leber,  Milz, 
Peritoneum,  ein  granulationsartiger  Herd  in  der  linken  Tibia. 

Klinisch  wird  von  den  Autoren  die  Ahnlichkeit  der 
Hautaffektion  mit  Tub.  verrucosa  hervorgehoben ;  auch  der 
Obduktionsbefund  schien  Tuberkulose  zu  ergeben.  Aber 
die  histologische  Untersuchung  ergab  neben  zahlreichen 
riesenzellenhaltigen  Infiltraten  im  Corium,  Epithelhyperplasie 
und  miliaren  Abszessen  im  Rete,  zahlreiche  doppelt  kon- 
turierte  kreisrunde  Parasiten  von  15-27  /«,  Durchmesser,  teils 
inter-,  teils  intrazellular,  welche  wie  oben  erwahnt  ursprung- 
lich  als  Protozoen  angesprochen,  spater  jedoch  von  Gilchrist 
selbst  und  von  Buschke  mit  grosser  Wahrscheinlichkeit  als 
Blastomyzeten  gedeutet  wurden.  Kultur  wurde  nicht  aus- 
gefuhrt,  Tierexperiment  nicht  einwandfrei. 

Den  3.  Typus  der  Blastomykose  reprasentiert  der  Fall 
von  Curtis.  Er  wurde  im  Juli  1895  vorlaufig  von  Curtis 
mitgeteilt. 

Ein  20  jahriger  Mann  mit  einem  faustgrossen  Tumor  der 
Inguinalgegend,  Beginn  vor  i|  Jahren;  spater  traten  Tumoren 
in  der  Haut  des  Stammes,  Nackens  und  der  Extremitaten 
hinzu,  welche  zum  Teil  zu  Geschwuren  zerfielen.  Exitus; 
Sektion  wurde  nicht  gemacht.  Histologisch  zeigten  sich 
die  Tumoren  zum  allergrossten  Teile  aus  ungeheuren  Mengen 
von  Hefepilzen  zusammengesetzt  und  nur  sehr  geringgradige 
entzundliche  Vorgange  sowohl  in  den  Tumoren  selbst  als 
auch  in  ihrer  Umgebung.  Kultur  und  Tierexperiment  positiv. 

Diese  drei  Typen  der  Haut  blast  omykose,  die  man  kurz 
am  besten  mit  den  Bezeichnungen  akut-pydmischer  Typus 
(Fall  Busse-Buschke) ,  chronischer  Hauttypus  (Gilchrist)  und 


352  SIXTH  INTERNATIONAL 

Tumorentypus  (Curtis)  belegen  konnte,  kommen  nicht  gleich 
haufig  vor.  Der  Curtische  Typus  ist  bis  jetzt  vereinzelt 
geblieben,  obwohl  es  manchen  Autoren  gelungen  ist,  bei 
Tieren  experimentell  ahnliche  Bilder  zu  erzeugen.  Der  akut- 
pyamische  Typus  wurde  mehrmals,  wenn  auch  selten  seit 
dem  Jahre  1894  beobachtet.  (Falle  von  Ormsby-Miller, 
Ophuls-Moffit,  Montgomery.)  Der  haufigste  Typus  ist  der 
der  chronischen  Hautblastomykose,  von  Gilchrist  zuerst 
beschrieben  und  wohl  auch  der  praktisch  hauptsachlich 
in  Betracht  kommende.  Bis  1903  waren  etwa  40  Falle 
in  Amerika  gesehen  worden;  in  Europa  war  die  Krankheit 
unbekannt.  Der  erste  derartige  Fall,  der  mit  grosser  Wahr- 
scheinlichkeit  in  die  Kategorie  dieser  chronischen  Haut- 
blastomykosen  gehort,  kam  am  16.  Februar  1903  in  unsere 
Klinik  und  wurde  von  mir  im  Marz  1903  in  der  Wiener  derma- 
tologischen  Gesellschaft  demonstriert.  Der  Fall  wurde  dann 
in  Gemeinschaft  mit  meinem  leider  so  fruh  verstorbenen 
Kollegen  Lowenbach  im  "  Archiv  f.  Dermatologie  u.  Syphilis" 
ausfuhrlich  publiziert.  Aus  dieser  Publikation  entnehmen 
wir  folgendes: 

Ein  26  jahriger  Feldarbeiter  aus  Mahren,  nie  ausserhalb 
Mahrens  und  Niederosterreichs  domizilierend.  Die  Affektion 
der  Nase  soil  seit  14  Jahren  bestehen. 

Die  Nase  zeigt  eine  Deformation  ihrer  hautigen  Anteile. 
Die  Haut  an  der  rechten  Ala  nasi  hat  eine  diffus  narbige 
Beschaffenheit,  ist  von  blaulichroter  Farbe,  so  dass  ein  ge- 
sprenkeltes  Aussehen  entsteht.  Die  Grenze  nach  oben  und 
gegen  die  Seitenteile  bildet  eine  unregelmassige  zackige 
Linie.  Das  buntscheckige  Aussehen  des  betroffenen  Be- 
zirkes  wird  noch  vermehrt  durch  eine  betrachtliche  Anzahl 
(20-25)  eigenartiger  KJnotchen.  Dieselben  sind  meist  hanf- 
korn-  bis  kaum  schrotkorn-gross.  Ihre  Farbe  ist  gelblichrot 
mit  einem  Stich  ins  livide,  ihr  Glanz  ein  betrachtlicher,  so 
dass  sie  stellenweise  durchscheinend  werden.  Sie  sind  kreis- 
rund  und  springen  halbkugelig  iiber  das  Niveau  der  Haut  vor. 
Die  Konsistenz  dieser  Knotchen  ist  ungemein  weich;  bei 
leiser  Beruhrung  mit  der  Nadelspitze  driickt  man  die  Ober- 
flache  wie  die  Kuppe  eines  Herpesblaschen  ein  und  beim 
Anstechen  tritt  eine  gelblichgraue,  dickliche  Masse  zutage. 


353 

An  einer  Stelle  ausserhalb  der  narbig  veranderten  Area, 
nach  aussen  vom  linken,  inneren  Augenwinkel,  zeigt  sich  eine 
Gruppe  analoger  Knotchen  in  einer  Reihe  angeordnet. 

Entsprechend  der  linken  Ala  nasi  wird  die  diffus  narbige, 
glatte  Flache  unterbrochen  von  einer  zackig  unregelmassig 
konturierten  tie  fen  Ulzeration,  welche  auf  die  mukose  Seite 
der  Nase  iibergreift  und  reichliches  seroses  Sekret  absondert. 
In  der  Umgebung  dieses  Geschwures  zeigen  sich  keinerlei 
an  Lupusknotchen  erinnernde  Gebilde,  dagegen  vereinzelte, 
den  kleinen  Knotchen  der  rechten  Nasenseite  und  des  Augen- 
winkels  ahnliche  Effloreszenzen  und  nach  aussen  gegen  die 
linke  Nasolabialfalte  hin  ein  Konglomerat  warzig  zerklufteter 
Effloreszenzen  vom  Aussehen  spitzer  Kondylome.  Im  hauti- 
gen  Nasenseptum,  i  cm.  oberhalb  des  Introitus,  besteht  eine 
runde  Perforationsoffnung  von  |  cm.  Durchmesser,  umgeben 
von  leicht  erodierten,  speckig  belegten,  hell  geroteten  Randern. 

Die  Diagnose  schwankte  zwischen  Lupus,  Syphilis  und 
Epitheliom  und  selbst  ein  so  hervorragender  Diagnostiker,  wie 
der  damalige  Chef  der  Klinik,  Hofrat  Neumann,  musste  dem 
klinischen  Bilde  der  Affektion  eine  Sonderstellung  einraumen. 
Diese  wurde  durch  die  mikroskopische  Untersuchung  des 
Inhaltes  der  kleinen  Knotchen  und  des  Sekretes,  sowie  durch 
histologische  Untersuchung  mehrerer  exzidierter  Hautpartien 
bestatigt.  Es  fanden  sich  namlich  im  Sekrete  in  grosser  Menge 
doppelt  konturierte,  stark  lichtbrechende,  kugelrunde  oder 
ellipsoide  Korper,  manchmal  mit  fein  granuliertem  Zentrum; 
bei  Zusatz  10%  iger  Kalilauge  wurden  sie  besonders  deutlich. 
Ihr  Durchmesser  betrug  3-5-12^;  an  manchen  Stellen  zeigten 
sich  kleine  Kugeln  in  Zusammenhang  mit  grosseren  Spross- 
formen.  Mit  Methylenblau,  Karbolfuchsin,  nach  Gram  und 
Weigert  waren  sie  leicht  farbbar.  Auch  in  den  Knotchen 
waren  diese  Gebilde,  die  ja  nur  als  Hefezellen  anzusprechen 
waren,  in  grosser  Menge  nachweisbar.  Die  histologische 
Untersuchung  ergab  intrakomeale  Pustelbildung  mit  miliarer 
Abszessbildung  in  der  Epidermis  nebst  Wucherung  der 
Stachelzellenschicht  und  stellenweise  machtigem  Infiltrat  des 
Papillarkorpers.  Allenthalben  fanden  sich  Blastomyzeten, 
reichlich  in  dem  Stratum  corneum,  sparlich  in  den  Abszessen 
und  Infiltraten.  Kulturversuche  und  Tierexperimente  waren 

VOL.  1—33 


354  SIXTH  INTERNATIONAL 

negativ;  dagegen  war  die  von  Bevan  empfohlene  Jodtherapie, 
Jodkali  in  steigenden  und  grossen  Dosen,  von  glanzendem 
Erfolge  begleitet.  Patient  wurde  nach  einer  4  wochentlichen 
Jodkur  geheilt  entlassen.  (Die  Veranderungen  des  klinischen 
Aussehens  durch  die  Behandlung  sind  auf  der  unserer  Ab- 
handlung  beigegebenen  Tafel  ersichtlich.)  Das  eigenartige 
klinische  Bild,  der  konstante  mikroskopische  Blastomyzeten- 
befund  im  Sekrete  im  Gewebe,  sowie  der  eklatante  Erfolg 
der  Therapie  bildeten  die  Veranlassung,  den  Fall,  trotz  des 
negativen  Ausfalles  der  Kulturversuche  und  Tierexperi- 
mente,  als  wahrscheinliche  Blastomyzeteninfektion  der  Haut 
hinzustellen. 

Wir  sprachen  damals  die  Vermutung  aus,  dass  manche 
Falle,  die  bisher  als  Lupus,  Syphilis  oder  Epitheliom  diag- 
nostiziert  worden  waren,  vielleicht  als  Blastomyzeteninfektion 
gedeutet  werden  konnen  und  dass  von  jetzt  ab,  da  die  Auf- 
merksamkeit  auf  diese  Affektion  gelenkt  worden  war,  gewiss 
auch  in  Europa  der  von  uns  beobachtete  Fall  nicht  isoliert 
bleiben  wurde.  Und  in  der  Tat,  im  letzten  Jahre  sind  mehrere 
Falle  dieser  Art  bekannt  geworden.  So  von  Sequeira  in  Lon- 
don, Dubreuilh  in  Frankreich,  Samberger  in  Prag  (2  Falle),  und 
auch  wir  hatten  Gelegenheit,  an  der  Klinik  Prof.  Finger,  drei 
weitere  Falle  von  wahrscheinlicher  Blastomyzeteninfektion 
zu  beobachten. 

Der  2.  Fall  wurde  vom  Kollegen  Brandweiner  im  "  Archiv 
f.  Derm.  u.  Syph."  unter  dem  Titel:  "  Zur  Frage  der  Blasto- 
mykose  der  Haut  und  uber  ihre  Beziehungen  zur  Folliculitis 
exulcerans  serpiginosa  nasi  (Kaposi) "  publiziert.  Brand- 
weiner identifiziert  namlich  beide  Krankheiten  und  auch 
das  spricht  fur  eine  Sonderstellung  des  klinischen  Bildes. 
Wieder  war  die  Affektion  an  der  Nase  lokalisiert. 

Bei  einem  37  jahrigen  Schuhmacher  aus  Galizien,  der  nie 
Oesterreich  verlassen  hatte,  zeigte  sich  die  Haut  der  linken 
unteren  Nasenhalfte  gerotet  und  infiltriert,  die  Rotung  ist 
unscharf  begrenzt.  Innerhalb  der  allmahlich  ausklingenden 
Rotung  finden  sich  braunrote,  eingestreute  Knotchen  von 
Hanfkorngrosse.  Die  meisten  dieser  tragen  im  Zentrum 
eine  Pustel,  deren  Inhalt  weissgelblich  durchschimmert.  Die 
zentralen  Anteile  der  Affektion  zeigen  Geschwure,  papillare 


DERMATOLOGICAL  CONGRESS  355 

Wucherungen  und  Narben.  Die  Geschwure  sind  meist  streif- 
enformig,  ihr  Grund  lochartig,  mit  braunlichen  Borken 
bedeckt.  Die  papillaren  Wucherungen  zeigen  hellrote  Farbe, 
blumenkohlartiges  Gefiige  und  erheben  sich  nur  wenig  iiber 
das  Niveau  der  Umgebung,  in  welchem  zahlreiche,  ziemlich 
junge  Narben  sichtbar  sind.  Diese  zeigen  unregelmassig 
zackige  Begrenzung,  sind  nicht  pigmentiert,  weisslich  oder 
hellrosa  und  fuhlen  sich  zart  an. 

Die  Affektion  besteht  nach  Angebe  das  Patienten  seit 
einem  halben  Jahr.  Der  histologische  Befund  einer  exzidier- 
ten  Hautpartie,  sowie  die  mikroskopische  Untersuchung  des 
Sekretes  ergab  dieselben  Resultate  wie  in  unserem  ersten 
Fall.  Ebenso  prompt  wirkte  Jodkali;  auch  hier  waren 
Kulturversuche  und  Tierinokulationen  negativ. 

Der  3.  und  4.  Fall,  die  wir  an  der  Klinik  Prof.  Finger 
beobachten  konnten,  sind  noch  nicht  publiziert;  iiber  den 
4. Fall  wurde  von  mir  am  Berliner  internationalen  Dermatologen- 
kongress,  gelegentlich  der  Blastomykosedebatte  im  Anschlusse 
an  die  Demonstration  der  Praparate  Dubreuilhs  referiert. 

Der  3.  Fall  ist  folgender: 

Malke  B.  (Journ.-Nr.  17.  200,  Prot.-Nr.  773,  Z.  74),  40 
Jahre  alt,  verheiratet,  Mutter  funf  gesunder  Kinder.  Die 
Nasenaffektion  begann  vor  zwei  Jahren  mit  Rotung  und 
Knotchenbildung.  Patientin  konsultierte  mehrere  Aerzte, 
die  mit  Salben  erfolglos  behandelten.  Sie  sucht  behufs 
Operation  ihres  "Lupus"  die  Klinik  auf.  Lues  negiert;  auch 
keine  Zeichen  einer  solchen;  kein  Abortus. 

Status  prasens  vom  9.  Juli  1903. 

Patientin  ist  klein,  von  grazilem  Knochenbau,  sehr  schlecht 
genahrt;  es  besteht  eine  hochgradige  Kyphose  der  Brust- 
wirbelsaule.  Innere  Organe  normal. 

Die  Nasenspitze  und  die  Nasenfliigel,  sowie  das  hautige 
Septum  duster  rot  gefarbt.  Die  Rotung  ist  am  intensivsten 
an  der  Spitze  und  dem  rechten  Nasenflugel  und  nimmt  all- 
mahlich  ab,  um  ungefahr  in  der  Mitte  des  Nasenriickens  in  die 
normale  Hautfarbe  uberzugehen.  Dabei  besteht  eine  gering- 
gradige  Anschwellung  der  geroteten  Partien.  Auf  diesen 
befinden  sich  einerseits  seichte  unregelmassige  konturierte 
Substanzverluste  von  Stecknadelkopf-  bis  uber  Linsengrosse, 


356  SIXTH  INTERNATIONAL 

die  einen  leicht  wegwischbarenspeckigen  Belag  zeigen,  ander- 
seits  hirsekomgrosse  Knotchen  von  gelblichweisser  Farbe 
und  eigentumlich  durchscheinender  Beschaffenheit.  Diese 
Knotchen  sowie  die  Substanzverluste  liegen  teils  oberflachlich, 
teils  in  Vertiefungen,  die  durch  kreuz  und  quer  verlaufende, 
kurze,  glanzende,  runde  Narbenstrange  gebildet  werden. 
Beim  Zerdriicken  oder  Anstechen  der  Knotchen  erscheint 
eine  klebrige  Flussigkeit.  Die  mikroskopische  Untersuchung 
dieser,  sowie  des  Sekretes  der  Geschwurchen  zeigt  neben 
Eiterzellen,  Detritus,  Epithelzellen,  Blutkorperchen  fast  aus- 
schliesslich  runde  oder  ovale  stark  lichtbrechende,  doppelt 
konturierte  Gebilde,  die  besonders  deutlich  bei  behandlung 
mit  30%  iger  Kalilauge  zum  Vorschein  kamen.  Auch  Formen, 
die  seitliche  Knospen  zeigten,  waren  sichtbar. 

Noch  deutlicher  war  dies  im  mit  Methylenblau  gefarbten 
Trockenpraparate.  Die  Grosse  dieser  Gebilde  variierte  von 
6-20  //  und  daruber,  sie  waren  verschieden  intensiv  farbbar 
und  zeigten  oft  im  Innern  Granulationen  und  Vakuolen.  Es 
konnte  kein  Zweifel  daruber  obwalten,  dass  diese  Korper 
den  in  meinem  ersten  Falle  dargestellten  hefeahnlichen  Zellen 
entsprachen,  und  ich  nahm  keinen  Anstand,  auch  diesen 
Fall  als  eine  wahrscheinliche  Blastomyzeteninfektion  der 
Haut  im  Sinne  der  Amerikaner  hinzustellen.  Der  Befund 
der  sprosspilzahnlichen  Gebilde  war  konstant  und  konnte 
auch  im  Gewebe  erhoben  werden. 

In  der  Umgebung  der  Nase  vereinzelte  Akneknotchen  und 
zahlreiche  Epheliden.  Das  Septum  und  die  Schleimhaut 
der  Nasenhohle  waren  intakt,  ebenso  die  Mundschleimhaut. 
Die  Haut  des  ubrigen  Korpers  zeigte  keine  Veranderung. 
Im  Urin  kein  Zucker,  kein  Eiweiss.  Blutbefund  normal. 

Der  Kranken  wurde  Jodkali  in  steigenden  Dosen  verordnet. 
Sie  erhielt  am  ersten  Tage  i  Essloffel  einer  Losung  (Kal. 
jodat.  10.00,  Aq.  dest.  200.00)  und  jeden  dritten  Tag  um 
einen  Essloffel  mehr,  bis  zu  8  Essloffel  pro  die.  Sie  vertrug 
diese  grossen  Jodkalidosen  ohne  Beschwerden.  Im  Verlaufe 
dieser  Therapie  besserte  sich  die  Nasenaffektion  zusehends. 
Schon  nach  14  Tagen  war  die  Rotung  nur  mehr  ausschliesslich 
auf  Nasenspitze  und  einen  Teil  der  Nasenflugel  beschrankt, 
die  Geschwurchen  waren  zum  grossen  Teile  uberhautet,  viele 


DERMATOLOGICAL  CONGRESS  357 

Knotchen  verschwunden.  Im  Inhalt  der  Knotchen  fanden 
sich  wohl  noch  Blastomyzeten,  doch  hatten  diese  an  Zahl 
bedeutend  abgenommen.  Auch  ihre  Farbbarkeit  war  geringer 
geworden,  indem  sich  viele  als  schwach  blassblau  gefarbte 
Scheiben  mit  dunkler  blau  gefarbten  Kontur  reprasentierten. 
Patientin  wurde  schliesslich  geheilt  entlassen,  nachdem  alle 
Erscheinungen  bis  auf  Rotung  der  Nasenspitze  geschwunden 
waren. 

Die  histologischen  Verdnderungen  sind  dreierlei  Art.  Sie 
betreffen  erstens  den  Bestand  von  kleinen  Abszessen,  teils 
subepidermoidal,  teils  intrakorneal,  zweitens  Epithelwuche- 
rungen  gegen  die  Kutis  zu  und  drittens  Zellinfiltrate  in  der 
Kutis  und  Subkutis. 

Was  die  Abszesse  betrifft,  so  fanden  sich  unter  dem  Stratum 
corneum  Anhaufungen  von  polynuklearen  Leukozyten,  zwis- 
chen  denen  man  zahlreiche  Blastomyzeten  in  alien  Stadium 
der  Sprossung  und  des  Wachstums  findet.  (Auch  in  dem 
Falle  hat  sich  die  Waelsch'sche  Modifikation  der  Weigert'- 
schen  Fibrinfarbung  zur  Darstellung  der  Mikro-organismen 
in  der  Hornschicht,  namlich  Farbung  durch  15  Minuten 
in  Anilinwasser,  zwei  Teile  Gentianaviolett,  alkoholische 
Losung  ein  Teil,  dann  Behandlung  der  Praparate  drei  Minuten 
lang  mit  einer  Mischung  von  5%  Jodkalilosung  mit  Wasser- 
stoffsuperoxyd  zu  gleichen  Teilen,  dann  Eintragen  der  Schnitte 
in  salzsaures  Anilinol  durch  etwa  funf  Stunden,  schliesslich 
Xylolbalsam  bewahrt.)  Mit  dieser  Methode  gelang  es,  die 
hefeahnlichen  Gebilde  elektiv  zu  farben.  Innerhalb  des 
Stratum  Malpighii  waren  nur  vereinzelt  solche  Herde  von 
Leukozyten  mit  Blastomyzeten  anzutreffen.  Die  subkor- 
nealen  Abszesse  entsprachen  den  eigentumlichen,  durch- 
scheinenden  Knotchen  des  klinischen  Bildes. 

Die  Epithelwucherung  trat  an  manchen  Stellen  als  Verbreit- 
erung  der  Malpighischen  Schicht  in  die  Erscheinung,  anderen 
Stellen  als  bedeutende  Entwicklung  der  Epithelzapfen,  die  weit 
in  die  Tief e  der  Kutis  hineinreichten  und  sich  vielf  ach  verzweig- 
ten.  Leukozyten  waren  nur  vereinzelt  im  Epithel  sichtbar. 

Die  Zellinfiltrate  der  Kutis  waren  aus  Rund-,  Epitheloid- 
und  zahlreichen  Riesenzellen  zusammengesetzt  und  erinnerten 
ganz  an  das  Bild  eines  Lupus  vulgaris.  Es  gelang  jadoch 


358  SIXTH  INTERNATIONAL 

mittels  der  Waelsch'schen  Methode,  zwischen  den  Zellen 
des  Infiltrates  Blastomyzeten,  wenn  auch  vereinzelt,  nach- 
zuweisen.  Diese  waren  manchmal  kreisrund  oder  oval, 
zeigten  einige  Male  homogene  Struktur,  manchmal  auch 
Granulation  en  und  Vakuolen  im  Innern.  Einzelne  der  Pilze 
waren  durch  aussen  anliegende  Zellen  abgeplattet  oder 
eingedruckt,  wenige  waren  in  Sprossung  begriffen. 

Selbstverstandlich  fanden  sich  die  Hefepilze  auch  in  den 
Lagen  des  Stratum  corneum  in  den  Haarbalgen,  zum  Teil 
dem  Haar  dicht  anliegend,  auch  in  den  Talgdriisen.  Dieses 
histologische  Bild  stimmt  vollstandig  mit  den  histologischen 
Beschreibungen,  die  von  amerikanischer  Seite  in  fast  alien 
als  Blastomyzetenerkrankung  beschriebenen  Fallen  gegeben 
wurden,  uberein,  namlich:  Miliare  Abszessbildung  in  Kutis 
und  Epidermis,  Zellinfiltrate  der  Kutis  mit  reichlichen  Riesen- 
zellen  und  Wucherungen  des  Epithets.  In  den  Abszessen  und 
Infiltraten  Blastomyzeten  nachweisbar . 

Die  Kulturversuche  waren  bisher  negativ,  obwohl  ich 
samtliche  Nahrboden,  die  fur  die  Kultur  von  Hefepilzen 
benutzt  worden  waren,  anwendete.  Ebenso  hatte  das  Tier- 
experiment  kein  positives  Resultat. 

Der  4.  Fall,  bei  dem  auch  Professor  Finger  das  Eigentum- 
liche  des  klinischen  Aspektes  anerkannte  und  die  Schwierig- 
keiten  der  differentiellen  Diagnose  hervorhob,  kam  am  21. 
Juli  1904  in  unsere  Klinik. 

J.  N.,  39  jahrigen  Schneider,  aufgenommen  21.  Juli  1904, 
Journ.-  Nr.  18.  649,  Prot.-Nr.  654.  Die  Erkrankung  begann 
vor  drei  Jahren  im  Nasen — innern  mit  Verstopftsein  der  Nase 
und  mit  haufigem  Nasenbluten;  ein  Jahr  spater  begann  die 
Hauterkrankung,  die  vergeblich  mit  den  verschiedensten 
Salben  behandelt  wurde. 

Bei  der  Aufnahme  zeigte  der  Kranke  folgendes  Bild:  Die 
Nase  flach,  verbreitert,  die  Nasenflugel  retrahiert,  die  Nasen- 
spitze  der  Oberlippe  genahert.  Die  Nase  bis  zur  Nasen wurzel 
lebhaft  gerotet,  die  Rotung  klingt  allmahlich  gegen  die  Umge- 
bung  ab ;  die  Nasenflugel  und  Spitze  verdickt,  diffus  infiltriert 
mit  gelben  fettigen  Krusten  und  Borken  bedeckt;  namentlich 
in  der  Nasolabialfurche  beiderseits  ist  die  Krustenauflagerung 
bedeutend  und  hier  sind  die  Infiltrate  gewulstet.  Im  Bereiche 


DERMATOLOGICAL  CONGRESS  359 

dieser  Infiltrationen  finden  sich  zahlreiche  seichte  deprimierte 
Narben,  welche  gelb  gesprenkelt  erscheinen.  Stellenweise  sind 
die  Ausfuhrungsgange  der  Talgdriisen,  wie  bei  Lupus  erythema- 
tosus  erweitert.  In  der  Umbegung  der  Nasenfliigel  finden  sich 
papillare  Exkreszenzen,  sowie  einige  akneartige,  weiche  Knot- 
chen.  Symmetrisch  zu  beiden  Seiten  des  Nasenruckens  und 
der  Nasenflugel  finden  sich  lebhaft  hellrote,  nur  wenig  elevierte 
und  infiltrierte,  von  feinen  Gefassen  durchzogene,  stellenweise 
mit  fettigen  Krusten  bedeckte,  etwa  guldengrosse  Herde,  welche 
zu  beiden  Seiten  der  Nase  und  an  den  oberen  Partien  der 
Wange  ein  blasses,  narbiges  Gebiet  umgeben.  Nach  ab warts 
gegen  die  Oberlippe  zu  sind  diese  Herde  ausgedehnter,  ohne 
narbiges  Zentrum,  nur  links  ist  die  zentrale  Narbenbildung 
angedeutet.  Sonst  sehen  diese  Flachen  wie  die  augen warts 
gelegenen  Umgrenzungsbander  aus,  hellrot,  wenig  eleviert 
und  infiltriert,  von  zahlreichen  Gefasschen  durchzogen.  Die 
Grenzen  gegen  die  gesunde  Wangenhaut  sind  unscharf;  nach 
abwarts  gehen  diese  Plaques  beiderseits  direkt  in  die  diffus 
geschwollene,  fast  dreifach  verdickte  Oberlippe  uber. 

Diese  ist  in  toto  diffus  duster  gerotet,  die  Rotung  scharf 
nach  links  und  rechts  gegen  den  noch  behaarten  Teil  der 
Oberlippe  abgegrenzt,  mit  dicken,  gelben  Krusten  bedeckt 
nach  deren  Ablosung  ein  leicht  blutendes,  nassendes,  glattes 
Gewebe  zum  Vorschein  kommt. 

Die  Schleimhaut  der  Mundhohle  ist  frei.  Das  Nasensep- 
tum  vom  Ubergang  des  knochernen  zum  knorpeligen  Anteil 
sowohl  nach  oben  als  nach  unten  perf oriert ;  die  Perf  orations- 
offnung  von  narbigen  Randern  umgeben. 

Patient  bekam  bis  zum  28.  September  335  g  Jodnatrium 
und  wurde  mit  folgendem  Status  entlassen:  An  der  Oberlippe 
ist  noch  eine  ganz  geringe  Verdickung  bemerkbar,  die  Haut 
derselben  ist  von  feingestrickter  blasser  Narbe  eingenommen. 
Die  Haut  der  Nase  und  der  seitlichen  Wangenpartien  blass, 
zum  Teil,  namentlich  in  den  seitlichen  Partien  eingenommen 
von  langlichen,  feinen  Narben,  welche  von  einem  wenig  er- 
habenen,  rotlich  gefarbten  Saum  umgeben  sind.  Die  rotliche 
Farbe  des  Saumes  ist  auf  kleine  Gefassektasien  zuriick- 
zufuhren.  In  diesen  Randern,  sowie  in  der  Haut  der  Narbe 
selbst,  auch  an  der  Nasenspitze  finden  sich  massenhaft  bis 


360  SIXTH  INTERNATIONAL 

stecknadelkopfgrosse,  hellgelb  hindurchschimmernde,  milien- 
artige  Gebilde.  An  der  Nase  rechts  und  in  der  Nasolabial- 
furche  links  zwei  linsengrosse  derbe  Atherome  von  braungelber 
Farbe. 

Im  Sekrete  und  in  den  Krusten,  sowie  im  Inhalte  der 
milienahnlichen  Gebilde  Blastomyzeten  zum  Teil  in  Sprossung 
begriffen.  Kulturversuche  auf  den  verschiedensten  Medien, 
sowie  Tierinokulationen  waren  negativ. 

Durch  Inokulation  mit  dem  Sekrete  am  rechten  Oberarm 
gelang  es,  nach  24  Stunden  eine  kleine  Blase  zu  erzeugen,  in 
deren  Inhalt  Blastomyzeten  nachweisbar  waren;  nach  zwei 
Tagen  war  die  Blase  spurlos  abgeheilt. 

Der  histologische  Befund  zeigte  insoferne  eine  Differenz 
von  den  drei  anderen  Fallen,  als  die  intra-epidermoidale  und 
intrakorneale  Pustelbildung,  die  miliaren  Abszesschen  voll- 
standig  fehlten.  Es  fand  sich  nur  ein  machtiges  Infiltrat 
im  Stratum  papillare  und  reticulare,  das  aus  Rund-,  Plasma- 
und  Riesenzellen  bestand. 

In  diesem  Infiltrate  fanden  sich  teils  vereinzelt,  teils  zu 
5-8  gruppiert  Blastomyzeten  in  charakteristischen  Formen. 
Es  gelang  auch,  diese  in  Gefassen  der  Kutis  nachzuweisen 
(Farbung,  Gram-Weigert  und  Waelsch).  Die  Wucherungs- 
vorgange  am  Epithel  waren  geringe;  es  fanden  sich  nur  spar- 
lich  verbreiterte  und  verlangerte  Epithelzapfen.  Die  gelben 
Punkte  der  Narben  waren  durch  erweiterte  und  vergrosserte 
Talgdriisen  hervorgerufen. 

Fassen  wir  die  klinischen  und  histologischen  Eigenheiten 
dieser  vier  Falle  zusammen,  so  ergibt  sich  fur  uns  folgendes: 

Das  klinische  wie  das  histologische  Bild  bildet  das  Resultat 
akuter  und  chronischer  Hautverdnderungen. 

Die  akuten  klinischen  Symptome  sind:  allmdhlich  gegen 
die  Umgebung  abklingende  helle  Rotung  und  Schwellung  mit 
oberfldchlicher  Pustelbildung.  Die  Pusteln  haben  einen  ganz 
eigenen  Typus.  Sie  gleichen  gelben  und  roten  Knotchen  von 
sehr  weicher  Konsistenz  und  durchscheinendem  Inhalt,  der 
sich  als  dicklich  und  fadenziehend  erweist.  Nach  Zerfall  der 
Pusteln  entstehen  seichte,  unregelmdssig  begrenzte,  lebhaft  sezer- 
nierende  Geschwure,  die  mit  zarten  Narben  ausheilen.  Die 
Narben  haben  ein  gelbgesprenkeltes  Aussehen. 


DERMATOLOGICAL  CONGRESS  361 

Histologisch  entspricht  diesem  Stadium  das  V  orhandensein 
von  intrakornealer  und  intraepithelialer  Abszessbildung;  zwischen 
Epidermis  und  Kutis  wurde  nie  ein  Abszess  beobachtet.  Die 
Epidermiszapfen  sind  meistens  verbreitert  und  verldngert,  das 
Stratum  papillare  entzundlich  infiltriert.  In  den  Abszess  en 
und  Infiltraten  Blastomyzeten  vereinzelt  oder  in  Gruppen,  aber 
me  zahlreich. 

Dieses  akutere  Stadium  der  Krankheit  gibt  bei  langerem 
Bestande  ein  Bild,  das  die  meisten  Falle  zeigen  und  das  dem 
Lupus  verrucosus  ahnlich  wird  (Gilchrist  beschrieb  seinen 
ersten  Fall  als  " Pseudolupus  verrucosus"}.  Man  sieht  dann 
wallartige  oder  gewulstete  Infiltrate,  blasse  narbige  Zonen  umge- 
bend,  Verdickungen  der  Nase  und  Lippen,  die  oberfldchlich 
exkoriiert  und  mit  Krusten  bedeckt  sind,  tiefe  Geschwure  mit 
unregelmdssigen  Randern  und  unebenem,  mit  dicken  Borken 
bedecktem  Grunde,  die  manchmal  den  Nasenftugel  konsumieren 
und  das  Septum  der  Nase  perforieren.  Auf  der  Basis  dieser 
Geschwure  kommt  es  zur  Bildung  papilldrer  Exkreszenzen, 
die  bald  die  Rander  der  Geschwure  uberragen,  dicht  angeordnet 
sind  und  stellenweise  an  den  Spitzen  Verhornung  zeigen. 

Histologisch  finden  sich,  abgesehen  von  Veranderungen 
der  Epidermis,  die  analog  den  fruher  geschilderten  sind,  dichte 
Infiltrationen  mit  Rund-,  Plasma-  und  Riesenzellen.  Die 
Infiltrate  durchsetzen  alle  Schichten  der  Kutis  und  gehen  noch 
in  die  Subkutis  hinein.  Dieses  Infiltrat  zeigt  teils  Neigung 
zum  eitrigen  Zerfall,  teils  zur  Narbenbildung;  in  ihm  findet 
man  spdrlich  die  Blastomyzeten. 

Alle  diese  klinischen  und  histologischen  Charaktere  sehen 
wir  in  den  vier  Fallen  in  verschiedener  Intensitat  und 
Kombination. 

Allen  gemeinsam  ist  das  Befallensein  der  Nase  und  die 
langere  Dauer  des  Prozesses.  Der  Fall,  der  die  kurzeste 
Krankheitsdauer  hatte  (Fall  2  Brandweiner) ,  zeigt  mehr  das 
akute  Stadium,  die  eigenartige  Pustelbildung,  die  helle, 
allmahlich  abklingende  Rotung,  die  seichte  Geschwurs-  und 
zarte  Narbenbildung,  die  anderen  Fallen  entsprechend  ihrer 
Dauer  auch  die  Kombination  der  Symptome. 

Fall  3,  Dauer  der  Affektion  2  Jahre,  durchscheinende 
Knotchen,  seichte  Geschwure,  zahlreiche  Narben  und  geringe 


362  SIXTH  INTERNATIONAL 

Verdickung  der  Nase;  Fall  4,  Dauer  der  Affektion  3  Jahre, 
neben  hellen,  von  Gefassen  durchzogenen  Rotungen  und  von 
diesen  begrenzten  Narben,  Infiltrationen  der  Nase  und  Ober- 
lippe,  papillare  Wucherungen  und  Perforation  des  Nasen- 
septums;  endlich  Fall  i,  der  die  langste  Krankheitsdauer 
hatte  (14  Jahre),  Knotchen,  Infiltrationen,  Zerstorung  des 
Nasenseptums,  des  einen  Nasenfliigels  und  zahlreiche  verrukose 
Wucherungen. 

Gemeinsam  war  auch  alien  4  Fallen  der  eklatante  Erfolg 
der  Jodtherapie. 

Was  die  Differentialdiagnose  betrifft,  so  kommen  in  erster 
Linie  in  Betracht  Lupus  vulgaris  und  hypertrophicus  papil- 
laris,  Tuberculosis  verrucosa,  Syphilis  und  Epitheliom,  in 
zweiter  Linie  Lupus  erythematosus  und  Acne  vulgaris  faciei. 
Gegen  Lupus  vulgaris  und  papillaris  hypertrophicus  sprechen 
die  hellrote  Farbe,  die  unscharfe  Begrenzung,  die  Perforation 
des  Nasenseptums  und  die  eigentumliche  Beschaffenheit  der 
Pustelknotchen ;  gegen  Tuberculosis  verrucosa  die  grosse 
Ausbreitung  der  Affektion,  die  Weichheit  der  papillaren 
Wucherungen  und  die  tiefen  Geschwure.  Von  Syphilis 
unterschied  sich  die  Affektion  durch  die  unregelmassige, 
unscharfe  Begrenzung,  die  hellrote  Farbe,  die  Unregelmassig- 
keit  der  Substanzverluste,  die  Zartheit  der  Narben;  vom 
Epitheliom  durch  die  Weichheit  der  Geschwiirsrander  und 
papillaren  Exkreszenzen,  die  Kombination  des  ulzerosen 
Prozesses  mit  den  eigenartigen  transparenten  Knotchen. 

Vom  Lupus  erythematosus  ist  die  Blastomykose  durch  die 
tiefen  Ulzerationen,  die  Perforation  des  Nasenseptums,  die 
gelblichroten  Knotchen,  die  unscharfe  Begrenzung  und  von 
der  Acne  confluens  faciei,  die  nur  wegen  der  manchmal  den 
Aknepusteln  ahnlichen  Knotchen  im  Anfangsstadium  der 
Krankheit  in  Betracht  kame,  durch  die  diffusen,  hellen  Ro- 
tungen und  durch  alle  iibrigen,  den  weiteren  Verlauf  der 
Affektion  charakterisierenden  Symptome  zu  unterscheiden. 

Sehr  gestutzt  wird  selbstverstandlich  bei  dem  nach  der 
Dauer  des  Leidens  sehr  wechselnden  Krankheitsbilde  erst 
dann  die  Diagnose,  wenn  in  den  Sekreten,  Borken  und  im 
Inhalte  der  Knotchen  Blastomyzeten  reichlich  und  in 
Sprossformen  konstant  zu  finden  sind  und  das  histologische 


DERMATOLOGICAL  CONGRESS  363 

Praparat  deren  Anwesenheit  nicht  nur  an  der  Oberflache 
der  Haut  und  in  Ansammlungen  polynuklearer  Leukozyten 
der  Epidermis  ergibt,  sondem  auch  in  den  Infiltraten  der 
Kutis  und  Subkutis. 

Freilich  ist  auch  dann  noch  immer  nicht  die  Blastomyzeten- 
natur  der  Erreger  dieser  Krankheit  und  deren  Sonderstellung 
uber  jeden  Zweifel  erhaben,  solange  nicht  Reinkultur,  Tierex- 
periment  und  Inokulation  auf  den  Menschen  gelungen  sind, 
wie  dies  ja  auch  in  unseren  Fallen  nicht  gelang.  Aber  auch  in 
etwa  20  Fallen,  die  in  Amerika  beobachtet  wurden,  darunter 
auch  Falle  von  Gilchrist,  waren  diese  Postulate  nicht  erfullt. 

Wir  glauben  daher  zur  Annahme  berechtigt  zu  sein,  dass 
man  Falle,  wie  die  vier  hier  beschriebenen,  deren  eigenartiges 
klinisches  Bild  von  Neumann  und  Finger  anerkannt  wurde, 
bei  denen  man  an  der  Oberflache  und  in  der  Tiefe  des  Gewebes 
hefenahnliche  Gebilde  konstant  und  elektiv  nachweisen  kann, 
trotz  des  negativen  Ausfalls  der  Kultur-  und  Impfversuche 
als  wahrscheinlich  durch  Blastomyzeten  verursacht  hinstellen 
und  sie  mit  dem  Namen  Hautblastomykose  bezeichnen  kann. 

Uber  die  Frage  des  Beginnes  der  Affektion  teilen  wir  die 
Ansicht  Buschkes,  dass  die  Hefen  von  aussen  her  in  die  Haut 
eindringen,  im  Gegensatz  zur  Ansicht  Busses.  Der  klinische 
Aspekt  der  Falle  erklart  dies  auch  ungezwungen.  Es  sind 
entweder  Blastomyzeten,  die  zuerst  als  harmlose  Schmarotzer 
in  den  Epidermislamellen  oder  in  den  Mundungen  der  Talg- 
drusen  lebten  und  dann  sei  es  durch  giinstigen  Nahrboden,  sei 
es  durch  Anderung  ihrer  Eigenschaften  pathogen  werden, 
oder  es  sind  von  vornherein  virulente  Sprosspilze.  Die 
kleinen  Ansammlungen  polynuklearer  Leukozyten,  die  bald 
in  der  Hornschicht,  bald  unter  dieser,  bald  im  Rete  Malpighii 
liegen  und  Blastomyzeten  enthalten,  kennzeichnen  den  Weg, 
den  diese  nehmen.  Dies  sind  die  miliaren  Abszesschen  nach 
der  amerikanischen  Beschreibung.  Werden  diese  grosser,  so 
bilden  sie  die  vielfach  erwahnten  transparenten,  glanzenden, 
gelbroten  Knotchen.  Haben  die  Blastomyzeten  die  Epi- 
dermis durchsetzt,  so  erzeugen  sie  im  Kutisgewebe  genau 
so  wie  die  Tuberkelbazillen  ein  Rund-,  Plasma-  und  Riesen- 
zellen  enthaltendes  Granulationsgewebe.  Von  hier  aus  kon- 
nen  sie  in  die  Blutbahn  gelangen*und  unter  Umstanden  eine 


364        SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

allgemeine,  pyamieahnliche  Infektion  mit  Hefepilzen  er- 
zeugen  (Falle  von  Busse-Buschke,  Montgomery-Walker, 
Ormsby-Miller,  Ophuls-Moffit,  Montgomery). 

Dass  die  von  uns  im  Sekrete  und  Gewebe  nachgewiesenen 
Gebilde  Blastomyzeten  seien,  wird  von  Unna  und  Neuberger 
bestritten.  Unna  behauptet  namlich  einerseits,  es  konne 
sich  um  Degenerationsprodukte  des  Elastins  handeln,  ander- 
seits  kame  auch  der  Flaschenbazillus  in  Betracht.  Dem 
gegeniiber  miissen  wir  festhalten,  dass  diese  sich  nach  Gram- 
Weigert  und  Waelsch  tief  blaufarbenden  Korper  an  Orten 
zu  finden  sind,  wo  nie  elastisches  Gewebe  zugrunde  gegangen 
ist  wie  im  Rete,  dass  sie  sich  mit  basischen  Farbstoffen  ebenso- 
gut  farben  lassen  wie  mit  sauren  (Fuchsin)  und  dass  die 
Formen  doch  viel  zu  regelmassig  und  eindeutig  sind,  als  dass 
man  diese  fur  die  wechselnden  Degenerationsprodukte  der 
elastischen  Fasern  halten  konnte. 

Gegen  die  Flaschenbazillennatur,  die  auch  von  Neuberger 
geltend  gemacht  wurde,  sprechen  die  intensive  Farbbarkeit 
und  die  deut lichen  Sprossformen. 

Praktisch  ergibt  sich  aus  der  Beobachtung  dieser  Falle, 
deren  Zahl  gewiss  in  der  nachsten  Zeit  zunehmen  wird,  dass 
wir  in  alien  Fallen,  in  denen  wir  zu  keiner  definitiven  Diagnose 
kommen  konnen,  weil  sich  eine  Affektion  nicht  unter  die 
bereits  bekannten  klinischen  Bilder  namentlich  des  Lupus, 
der  Syphilis  und  des  Epithelioms  einreihen  lasst,  zum  Mikro- 
skope  greifen  miissen,  das  erst  die  Sonderstellung  eines  solchen 
Falles  wahrscheinlich  macht.  Dann  wissen  wir  aber  auch, 
dass  wir  in  grossen  Joddosen  ein  Mittel  haben,  um  der  Blasto- 
myzeteninfektion  der  Haut  wirksam  zu  begegnen. 


SYSTEMIC  BLASTOMYCOSIS:  ITS  ETIOLOGICAL, 
PATHOLOGICAL,  AND  CLINICAL  FEATURES, 
AS  ESTABLISHED  BY  A  CRITICAL  SURVEY 
AND  SUMMARY  OF  TWENTY-TWO  CASES 
(EIGHT  OF  THEM  UNPUBLISHED) ;  THE  RE- 
LATION OF  BLASTOMYCOSIS  TO  COCCIDI- 
OIDAL  GRANULOMA 

BY  DR.  FRANK  HUGH  MONTGOMERY  AND  DR.  OLIVER  S.  ORMSBY, 

OF  CHICAGO 

Since  Gilchrist  in  America  and  Busse  and  Buschke  in 
Germany  first  described  the  infectious  disease  now  generally 
known  as  blastomycosis,  about  one  hundred  cases  involving 
the  skin  have  been  recognized,  chiefly  in  Chicago  and  its 
vicinity,  but  also  in  other  parts  of  the  United  States,  in  Canada, 
in  various  parts  of  Europe,  in  Japan,  India,  and  South  America. 
In  consequence,  cutaneous  blastomycosis  is  generally  accepted 
by  dermatologists  and  pathologists  throughout  the  world 
as  a  distinct  clinical  and  pathological  entity.1 

It  is  not,  however,  so  generally  understood  that  deeper- 
seated  infection  with  these  same  organisms  may  result  in 
grave  and  usually  fatal  systemic  disease.  The  purpose  of 
this  paper  is  to  call  attention  to  a  number  of  recorded  and 
unrecorded  cases  of  systemic  blastomycosis  and  to  sum- 
marize and  classify,  in  so  far  as  is  now  possible,  the  etiological, 
pathological,  and  clinical  features  of  the  disorder.  We  have 

1  (For  a  general  discussion  of  cutaneous  blastomycosis  see  a  paper  by  one 
of  us  (Montgomery),  Journ.  Amer.  Med.  Assn.,  June  7,  1902.  This  gives 
a  summary  of  the  clinical,  pathological,  and  bacteriological  features  of  the 
disease,  with  sixteen  clinical  illustrations  and  twenty-five  illustrations  of 
the  histology  and  bacteriology;  a  briefer  summary  in  Hyde  and  Montgomery's 
Diseases  of  the  Skin,  7th  ed.;  a  general  summary  by  Gilchrist,  Brit.  Med. 
Journ.,  1902,  p.  1321;  and  original  reports  of  many  cases  since  January, 
1900,  in  Journ.  Cutan.  Dis.,  and  other  journals.) 

365 


366 

collected  twenty-two  cases  (eight  not  yet  published),1  in  which 
the  diagnosis  of  systemic  blastomycosis  has  been  demonstrated 
beyond  question  by  histological  and  bacteriological  study 
of  the  lesions,  and  in  eleven  instances  by  autopsy.  In  ad- 
dition to  the  twenty-two  unquestionable  cases  on  which  this 
paper  is  based,  we  have  added  brief  notes  of  five  other  cases 
in  which  blastomycetes  were  demonstrated  in  local  lesions 
or  in  the  sputum,  and  in  which  all  clinical  signs  pointed  to 
systemic  infection,  but  in  which  the  final  proof  of  such  in- 
fection is  wanting. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — The  cases  in 
the  appended  summary  are  arranged  in  order  of  publication. 
Busse  and  Buschke's  case  of  cutaneous  and  systemic  blasto- 
mycosis was  first  reported  by  Busse  in  1894,  a  few  weeks  after 
Gilchrist  had  demonstrated  before  the  American  Derma- 
tological  Association-  his  sections  from  a  cutaneous  lesion. 
The  Curtis  case  was  published  in  1896.  The  first  American 
case  of  systemic  blastomycosis  (No.  3)  was  under  observa- 
tion in  1894-5,  but  its  true  nature  was  not  discovered  until 
five  years  later,  through  examination  of  the  sections  and 
tissue  which  had  been  preserved.  Sixteen  of  the  cases  here- 
with tabulated  have  been  recorded  within  the  last  two  years. 

The  residences  of  the  twenty-two  patients  at  the  time 
of  acquiring  the  disease  were,  as  nearly  as  can  be  determined, 
as  follows:  Chicago,  thirteen;  Iowa,  two;  Indiana,  Wisconsin, 
Ohio,  Maryland,  New  York  City,  Germany,  and  France,  one 
each.  The  Wisconsin  patient  probably  acquired  his  disease 
while  working  in  one  of  the  southern  states.  The  true  nature 
of  the  Indiana,  Wisconsin,  and  Ohio  cases  was  discovered 
when  the  patients  were  in  Chicago  for  examination  and  treat- 
ment. Though  it  is  evident  that  blastomycosis,  both  cu- 
taneous and  systemic,  occurs  most  frequently  in  Chicago  and 
its  vicinity,  it  is  probable  that  one  reason  why  so  many  re- 
ports come  from  this  city  lies  in  the  fact  that  a  number  of 
Chicago  physicians  have  become  familiar  with  the  disorder 
and  are  on  the  lookout  for  it. 

1  Four  of  these  will  be  published  in  full  later  by  some  of  our  Chicago 
colleagues  who  have  kindly  permitted  us  to  make  abstracts  from  their 
notes. 


DERMATOLOGICAL  CONGRESS  367 

ETIOLOGY. — Predisposing  causes,  aside  from  those  which 
favor  any  infection,  cannot  be  recognized  in  the  study  of  the 
twenty-two  cases.  Family  and  personal  histories  are  in  the 
main  negative.  There  is  no  evidence  of  inheritance,  or  con- 
tagion, though  in  one  of  the  doubtful  cases  (E)  there  were 
two  and  possibly  three,  individuals  of  the  same  family  with 
lesions  showing  infection  with  blastomycetes.  Of  the  twenty  - 
two  patients  nineteen  were  males  and  three  females.  The 
ages  varied  from  17  to  58,  seventeen  being  between  20  and 
47,  the  period,  usually,  of  greatest  activity  and  consequently 
of  most  frequent  exposure  to  infections.  The  occupation  of 
sixteen  of  the  nineteen  men  is  given  as  follows:  Laborers, 
seven;  farmers,  three;  machinists,  two;  engineer,  carpenter, 
policeman,  and  convict,  each  one.  Of  the  three  women,  one 
was  employed  on  a  farm,  one  was  a  German  housewife,  the 
other  was  a  young  married  woman  with  no  occupation.  The 
hygienic  surroundings  and  financial  condition  of  the  patients 
were  unfavorable  in  the  majority  of  cases. 

The  active  and  essential  cause  of  the  disease  is  infection  with 
organisms  which  for  the  want  of  a  more  exact  and  satisfactory 
term  are  designated  as  blastomycetes.  That  these  organisms 
are  the  pathological  factors  in  these  cases  has  been  clearly 
demonstrated:  (i)  by  finding  the  organisms  in  pus  and  tissue; 
(2)  by  obtaining  them  in  pure  culture  from  subcutaneous 
abscesses,  and  at  autopsies  from  miliary  nodules  and  abscesses 
of  internal  organs;  (3)  by  reproduction  of  the  disease  in  guinea- 
pigs  and  other  animals  after  inoculation  with  pure  cultures, 
and  recovery  of  the  organism  in  pure  cultures  from  the  gen- 
erally disseminated  lesions  in  these  animals.  (See  Cases  1,2, 
4,  5,  8,  9,  14,  and  18.)  The  organisms  are  pyogenic  and  are 
readily  obtained  in  pure  culture  from  any  of  the  unbroken 
abscesses. 

Tuberculosis  has  been  excluded  from  all  the  cases  by  ex- 
amination of  secretions  and  tissues.  In  Cases  i,  2,  3,  5,  7,  8, 
9,  12,  14,  and  18,  a  thorough  search  was  made  for  any  possible 
complicating  tuberculosis,  not  only  by  examination  of  se- 
cretions and  tissues  but  also  by  the  inoculation  of  guinea- 
pigs,  while  in  Cases  5,7,  and  14  the  tuberculin  test  and  cultures 
were  also  employed.  Only  in  Case  n,  in  which  late  in  the 


368  SIXTH  INTERNATIONAL 

disease  tubercle  bacilli  were  found  in  the  sputum,  was  any 
such  complication  detected.  It  is  true  that  in  Case  3,  after 
prolonged  search  three  or  four  bacilli  with  staining  qualities 
like  those  of  tubercle  bacilli  were  demonstrated  in  a  small 
open  ulcer  of  the  skin,  but  the  exact  nature  of  these  bacilli 
was  not  demonstrated,  and  they  were  undoubtedly  present 
as  the  result  of  secondary  infection,  since  tissue  from  these 
same  lesions  inoculated  into  several  guinea-pigs  failed  to 
produce  tuberculosis. 

Infection  Atrium  and  Mode  of  Dissemination. — At  each 
of  the  eleven  autopsies  the  lungs  were  found  to  be  more  or 
less  extensively  involved;  in  several  instances  with  broncho- 
pneumonia.  In  a  number  of  cases  the  earliest  symptoms 
were  pulmonary,  and  blastomycetes  were  demonstrated  in 
the  sputum.  These  facts  would  point  to  the  respiratory  tract 
as  a  common  point  of  infection  through  the  inhalation  of  par- 
ticles of  dust  carrying  the  organisms.  In  Cases  3  and  4, 
typical  cutaneous  lesions  had  existed  for  seven  and  four  years, 
respectively,  before  systemic  infection  occurred.  In  Case  12, 
there  is  a  history  of  a  wound  of  the  foot,  with  the  first  manifes- 
tations of  the  disease  appearing  in  the  adjacent  tissues.  In 
the  majority  of  the  cases,  however,  and  especially  in  those 
in  which  the  first  symptoms  were  indolent  subcutaneous 
abscesses,  the  point  of  inoculation  cannot  be  determined. 

That  the  mode  of  extension  is  the  same  as  in  other  pyaemias, 
through  the  blood  instead  of  by  way  of  the  lymphatics,  is 
evident  from  the  wide  and  often  rapid  dissemination  of  deep- 
seated  lesions  with  little  or  no  involvement  of  the  lymph 
glands,  and  from  the  fact  that  blastomycetes  have  been 
demonstrated  in  the  blood  in  Cases  i  and  19,  and  in  sections 
of  blood  vessels  in  a  number  of  instances.  Enlarged  lymph 
glands  were  noted  clinically  in  Cases  i,  4,  5,  7,  and  19,  and  at 
the  autopsy  in  Cases  i,  7,  8,  14,  19,  and  20,  but  in  no  instance 
was  the  involvement  of  lymph  glands  a  prominent  feature. 

The  organisms  are  apparently  identical  with  those  found 
in  cutaneous  blastomycosis  and  as  these  have  been  described 
fully  and  repeatedly,  the  subject  will  be  considered  very 
briefly  here.  In  unstained  preparations  of  pus  and  tissue, 
the  organisms  appear  as  round  or  oval  bodies  with  a  double- 


DERMATOLOGICAL  CONGRESS  369 

contoured,  highly  refractive  capsule.  Within  the  capsule 
in  many  instances  granules,  or  spore-like  bodies,  can  be 
distinguished.  The  addition  of  a  one  to  ten  per  cent,  solution 
of  potassium  hydrate  to  the  specimen  under  examination 
facilitates  the  recognition  of  these  bodies.  In  stained  sections 
the  double-contoured,  homogeneous  capsule  is  usually  sepa- 
rated from  a  finely  or  coarsely  granular  protoplasm  by  a  clear 
space  of  varying  width.  Vacuoles  of  different  sizes  are  found 
in  some  organisms.  In  both  pus  and  tissue,  organisms  in  pairs 
or  in  various  stages  of  budding  are  commonly  seen.  The  para- 
site varies  in  size,  as  a  rule,  from  seven  to  twenty  microns, 
though  slightly  smaller  and  much  larger  forms  occur  in  some 
cases. 

The  organisms  are  readily  obtained  in  pure  culture  from 
unbroken  abscesses,  from  miliary  abscesses  in  the  borders  of 
the  cutaneous  lesions,  and  from  the  miliary  nodules  and 
abscesses  in  the  deep-seated  organs.  Cultures  were  obtained 
in  all  the  cases  here  reported  except  3  and  6,  in  which  the 
nature  of  the  disease  was  discovered  by  histological  examina- 
tion of  tissues  after  death.  The  parasites  grow  well  on  glycer- 
ine- and  glucose-agar,  blood  serum,  broth,  and  other  ordinary 
culture  media.  A  macroscopical  growth  is  usually  seen  in 
from  two  to  fourteen  days;  in  sub-cultures  from  thirty  hours 
to  fourteen  or  more  days.  The  gross  and  microscopic  forms 
of  the  organism  in  any  one  case  may  be  made  to  vary  widely 
with  the  media  employed  and  with  the  temperature  and  other 
conditions  of  growth.  As  a  rule,  the  growth  is  more  or  less 
moist  on  glycerine-agar,  but  dry  and  showing  abundant 
aerial  hyphae  on  glucose-agar.  At  room  temperature  there  is 
a  greater  tendency  on  all  media  to  a  drier  growth  and  a  greater 
development  of  aerial  hyphae  than  in  the  incubator,  where 
the  growth  is  commonly  more  moist  and  pasty.  Moist  growths 
on  glucose-agar  taken  from  the  incubator  and  grown  at  room 
temperature  become  dry  and  develop  abundant  aerial  hyphae. 
Old  cultures  on  glycerine-agar  usually  form  a  rough,  granular, 
or  angle-worm  appearance  of  a  light  brown  color. 

Microscopically,  room-temperature  cultures  appear  at  first 
as  a  fine  branching  mycelium  with  a  few  small,  spore-like 
bodies.  Later,  a  large,  segmented,  often  pod-like  mycelium 

VOL.  I 24 


370  SIXTH  INTERNATIONAL 

appears,  together  with  large,  round,  or  oval  bodies  with  bud- 
like  projections.  Many  small  spore-like  bodies  are  frequently 
seen  within  the  larger  mycelium  and  large  round  bodies,  or 
in  groups  near  a  ruptured  capsule,  but  the  development  of 
these  small  bodies  into  adult  forms  has  not  been  demon- 
strated. Cultures  grown  in  the  incubator  usually  show  at 
first  budding  forms  apparently  identical  with  those  seen  in 
tissue  and  in  pus. 

The  cultural  features  of  the  organisms  as  reported  by 
different  observers  in  different  cases  have  varied  considerably. 
It  does  not  follow,  however,  that  the  parasites  varied  so  much 
as  the  reports  would  imply,  for  with  the  organism  from  a 
single  case  we  have  produced  practically  all  the  morphological 
varieties  previously  described  by  ourselves  and  others.  The 
futility  of  any  attempt  to  form  a  classification  based  on 
morphology  alone  is  thus  apparent.  The  number  and  varieties 
of  pathogenic  fungi  of  this  group  can  be  determined  only  by  a 
comparative  study  of  them  all  on  uniform  lines  and  with  ab- 
solutely the  same  technique.1  As  it  has  been  demonstrated 
that  there  are  a  number  of  yeasts  pathogenic  for  animals, 
and  as  Hanson  has  shown  that  yeasts  rarely  occur  singly 
in  nature  but  rather  in  groups  of  two  or  more,  it  is  quite 
possible  that  in  the  majority  of  cases  of  blastomycosis  there 
may  be  present  two  or  three  varieties  of  a  given  species.  Such 
an  hypothesis  would  explain  some  of  the  cultural  and  other 
phenomena  we  have  observed. 

PATHOLOGY. — Aside  from  the  marked  tendency  to  pus 
formation,  the  gross  pathology  of  systemic  blastomycosis  so 
closely  resembles  that  of  tuberculosis  that  in  some  of  the 
earlier  autopsies  the  presence  of  large  numbers  of  minute 
nodules  in  different  organs  led  to  a  macroscopic  diagnosis  of 
miliary  tuberculosis.  The  formation  of  multiple  abscesses 
(especially  subcutaneous  abscesses),  with  the  resulting  sinuses, 
ulcers,  and  scars,  is,  however,  one  of  the  characteristic  features 
of  the  disorder.  These  abscesses  may  be  microscopic  in 
size  or  they  may  be  large  enough  to  hold  a  litre  of  pus.  They 
may  burrow  deeply,  involving  the  muscles,  laying  bare  the 

1  This  has  been  done  with  the  organisms  of  four  cases,  by  Hamburger, 
Journ.  Infect.  Dis.,  1907,  iv.,  p.  201. 


DERMATOLOGICAL  CONGRESS  371 

tendons,  causing  erosion  and  caries  of  bones,  and  invading 
the  joints,  or  their  origin  may  be  in  deeper  tissues  producing 
large  thoracic,  abdominal,  or  pelvic  abscesses.  Multiple 
miliary  to  pea-sized  and  larger  abscesses  may  occur  in  any 
or  all  of  the  organs  of  the  body,  but  are  especially  common 
in  the  lungs  and  spleen,  which  in  some  instances  were  com- 
pletely riddled  and  largely  destroyed.  In  several  instances 
vertebrae,  and  in  one  case  several  inches  of  the  spinal  cord, 
were  completely  destroyed.  The  bone  involvement  may 
occur  as  a  blastomycotic  osteomyelitis  as  shown  in  Case  19. 

The  histological  appearances  also  strongly  suggest  those  of 
tuberculosis,  but  again  differ  from  it  especially  in  the  abscess 
formation  and  in  the  presence  in  the  nodules  of  greater  num- 
bers of  polymorphonuclear  leucocytes.  A  small  nodule  in 
the  lung  which  closely  resembles  in  appearance  a  miliary 
tubercle  is  seen  to  have  the  following  component  parts:  In  its 
centre  is  a  necrotic  mass  surrounded  by  giant  cells,  outside 
of  which  is  a  zone  of  granulation  tissue.  The  necrotic  centre 
contains  blastomycetes,  polymorphonuclear  leucocytes,  red 
blood  corpuscles,  and  desquamated  epithelial  cells.  Sur- 
rounding this  mass  are  varying  numbers  of  giant  cells  of  the 
Langhans  type  and  embryonic  connective  tissue  cells.  The 
giant  cells  nearly  all  contain  blastomycetes  in  varying  numbers, 
sometimes  being  crowded  full  of  them.  Outside  of  this  area 
are  found  plasma  and  small  round  cells,  some  connective  tissue 
fibres,  and  distended  capillaries.  In  these  areas  the  alveolar 
walls  are  often  not  demonstrable  and  in  the  bronchioles  des- 
quamated epithelial  cells,  blastomycetes,  cellular  detritus,  and 
pigment  are  found.  In  some  sections  all  that  remains  to  show 
the  former  presence  of  bronchioles  is  the  deposit  of  peribronchial 
coal  dust.  At  a  distance  from  the  blastomycotic  broncho- 
pneumonic  process,  oedema  of  the  lung  tissue  occurs.  In  cases 
where  greater  destruction  has  ensued  as  a  result  of  more  active 
multiplication  of  the  organisms,  the  identity  of  the  lung  tissue 
is  practically  lost,  its  place  being  occupied  by  great  numbers 
of  the  parasites,  giant  and  other  cells  peculiar  to  the  granulo- 
mata,  cellular  detritus,  and  large  amounts  of  pigment.  The 
peribronchial  lymph  nodes  contain  blastomycotic  nodules 
similar  to  those  described  above,  sections  of  which  show  less 


372  SIXTH  INTERNATIONAL 

advanced  areas  of  necrosis  surrounded  by  granulation  tissue. 
The  giant  cells  at  times  contain  pigment  as  well  as  the  usual 
organisms. 

The  smaller  areas  in  the  spleen,  kidneys,  pancreas,  adrenals, 
etc.,  show  as  a  rule  collections  of  blastomycetes  and  necrotic 
tissue,  the  necrosis  being  less  marked  than  in  the  lungs  and 
giant  cells  less  frequent.  No  giant  cells  have  as  yet  been  seen 
in  the  spleen.  In  bones  necrotic  areas  containing  the  organism 
in  abundance,  surrounded  by  leucocytes,  giant  cells,  and  other 
cells  peculiar  to  the  granulomata,  have  been  noted  in  several 
instances  and  fully  described  in  Case  8. 

In  the  deeper  abscesses  (retropharyngeal,  deep  subcu- 
taneous, etc.),  sections  from  the  lining  of  the  abscess  cavities 
show  necrotic  tissue,  blastomycetes,  and  leucocytes,  chiefly 
polynuclear,  surrounded  by  giant  cells  and  small  round  cells 
and  fibroblasts,  the  giant  cells  containing  blastomycetes. 

Sections  from  a  deep  unruptured  nodule  in  the  skin  showed 
its  metastatic  origin.  It  was  a  beginning  abscess  situated 
chiefly  in  the  hypoderm,  the  overlying  epidermis  being  un- 
altered. The  upper  part  of  the  corium  showed  little  change, 
while  in  the  lower  part  some  oedema  and  moderate  degenera- 
tion of  the  collagen  was  present.  In  the  hypoderm  the  nod- 
ule presented  in  its  centre  blastomycetes,  in  groups,  in  pairs 
and  singly,  polymorphonuclear  leucocytes,  and  red  blood  cells. 
Surrounding  this  were  numerous  giant  cells  of  the  Langhans 
type,  plasma  and  connective  tissue  cells.  At  the  margins 
were  some  fibroblasts.  The  giant  cells  here  all  contained  the 
organisms. 

While  as  a  rule  there  appears  to  be  a  certain  amount  of 
uniformity  in  the  arrangement  of  the  component  parts  of  this 
granuloma  in  different  parts  of  the  body,  many  sections  show 
no  such  arrangement,  but  rather  an  indefinite  commingling 
of  the  various  cells  with  the  blastomycetes.  Ordinary  fixing 
and  staining  methods  suffice  to  demonstrate  the  organisms, 
which  are  found  both  within  the  giant  cells  and  free.  Hema- 
toxylin-eosin,  polychrome  methylene  blue,  and  LoefBer's 
alkaline  methylene  blue  are  most  commonly  employed. 
Metachromism  is  at  times  shown  in  the  granules  in  the  organ- 
isms when  metachromatic  stains  are  employed. 


DERMATOLOGICAL  CONGRESS  373 

It  is  worthy  of  note  that  notwithstanding  the  presence  of 
suppuration  in  all  of  the  cases,  in  three  only  (5,  6,  and  8)  was 
amyloid  degeneration  recognized,  and  in  only  one  instance 
(Case  8)  were  these  changes  at  all  extensive.  In  this  case 
amyloid  was  noted  in  the  spleen,  liver,  kidneys,  adrenals, 
retroperitoneal  and  mediastinal  lymph  nodes,  and  colon. 

In  ten1  cases  of  which  full  autopsy  reports  are  available, 
lesions  distinctly  blastomycotic  in  character  were  demonstrated 
in  the  following  organs  and  tissues :  lungs,  in  all  cases ;  pleura, 
in  Cases  5,7,19,  and  20 ;  larynx,  in  Case  5 ;  trachea  and  bronchi, 
in  Cases  5,  7,  and  8;  thyroid  cartilage,  in  Case  9;  retropharyn- 
geal  and  subpleural  tissues,  in  Case  7 ;  myocardium,  in  Case  6 ; 
cerebrum  and  cerebellum,  in  Cases  7  and  19;  spinal  cord,  in 
Case  18;  external  spinal  dura,  in  Case  7;  spleen,  in  Cases  i,  3, 
5,  6,  9,  14,  19,  and  20;  liver,  in  Cases  3,  5,  6,  and  7;  kidney,  in 
Cases  i,  3,  5,  6,  7,  9,  19,  and  20;  adrenals,  in  Case  6;  pancreas, 
in  Case  5;  colon  in  Case  7;  appendix  vermiformis,  in  Case  14; 
prostate,  in  Cases  19  and  20;  psoas  and  other  deep  abscesses, 
in  Cases  8,  9,  and  14;  bones,  not  including  spinal  column,  in 
Cases  i,  7,  8,  9,  19,  and  20;  spinal  column,  in  Cases  7,  8,  18, 
and  19;  joints,  in  Cases  7,  18,  and  19;  lymph  nodes,  in  Cases 
7,  8,  14,  19,  and  20;  muscles  in  Cases  19  and  20.  Cultures 
of  the  blastomycetes  were  obtained  from  the  pericardial  and 
pleural  cavities  in  Case  20;  from  the  blood,  in  Cases  i  and  19; 
organisms  were  demonstrated  in  sections  of  blood-vessels 
in  Cases  5,  8,  and  9. 

The  blastomycotic  nature  of  the  subcutaneous  abscesses 
was  demonstrated  in  each  case  by  cultures  or  examination  of 
smears.  The  histology  of  a  subcutaneous  nodule  is  described 
in  detail  in  Case  5.  Sections  of  many  of  the  cutaneous  ulcers 
were  made  showing  the  characteristic  features  of  cutaneous 
blastomycosis. 

Among  other  morbid  conditions  noted  at  autopsy  in  these 
various  cases  were  the  following:  laryngitis,  adenoma  of  the 
thyroid,  colloid  goitre,  fibrous  and  sero-fibrinous  pleuritis, 

1  Regarding  one  of  the  eleven  autopsies  (Case  18),  we  have  only  Dr. 
Evans's  verbal  statement  that  blastomycotic  lesions  were  distributed 
generally  throughout  the  body  and  that  several  vertebrae  and  a  portion  of 
the  spinal  cord  were  destroyed. 


374  SIXTH  INTERNATIONAL 

purulent  bronchitis,  broncho-pneumonia,  pulmonary  oedema, 
fibroid  induration  of  the  lungs,  pericarditis,  atrophy  of  the 
heart,  perihepatitis,  parenchymatous  degeneration,  fatty 
changes;  adenoma,  angioma,  and  atrophy  of  the  liver;  nephritis, 
retention  cysts  of  the  kidney,  hyperplastic  splenitis,  atrophy 
of  the  testicles,  and  tigrolysis  of  ganglion  cells  of  the  cerebral 
cortex  and  ventral  horns  of  the  cord. 

Animal  experiments  have  demonstrated  the  pathogenicity 
of  blastomycetes  for  guinea-pigs,  white  mice,  rats,  rabbits, 
and  dogs.  The  inoculations  were  far  from  uniformly  suc- 
cessful, many  animals  showing  little  or  no  reaction  and  on 
those  that  were  successful  a  very  large  dosage  was  required- 
The  best  results  followed  intraperitoneal  and  intravenous  in- 
jections of  pure  cultures,  and  were  most  marked  in  those 
animals  killed  about  three  weeks  after  inoculation.  Several 
guinea-pigs  in  which  a  general  systemic  infection  was  indi- 
cated by  irregular  fever,  lasting  a  number  of  weeks,  by  loss 
of  weight,  and  even  by  the  formation  of  palpable  abdominal 
tumors,  eventually  made  a  complete  recovery,  showing  their 
ability  to  overcome  the  disease.  Local  lesions  induced  by 
subcutaneous  inoculation  usually  healed  in  a  few  weeks.  The 
gross  and  microscopic  findings  in  animals  were  similar  to  those 
found  in  man.  In  the  various  animals  the  following  structures 
showed  blastomycotic  ulcers,  nodules,  miliary  tubercles,  and 
abscesses:  The  skin,  subcutaneous  tissue,  lungs,  pleura,  dia- 
phragm, liver,  spleen,  kidneys,  mesentery,  omentum,  testicles; 
mediastinal,  mesenteric,  and  inguinal  lymph  glands;  and  in 
one  instance  the  placenta.  The  involvement  to  a  marked 
degree  of  the  testicles  after  intra-peritoneal  inoculation  cor- 
responds to  results  obtained  with  the  organisms  of  coccidioi- 
dal  granuloma  after  similar  inoculations. 

CLINICAL  FEATURES. — The  common  and  most  pronounced 
feature  of  all  the  cases  (except  Case  6  in  which  there  was  but 
one  abscess)  has  been  the  formation  sooner  or  later  of  multiple 
abscesses  in  various  parts  of  the  body,  with  the  accompanying 
symptoms  of  a  chronic  pyaemia  in  the  form  of  an  irregular 
moderate  fever,  malaise,  loss  of  strength,  and  emaciation.  In 
addition  many  of  the  cases  have  presented  symptoms  due 
to'the  location  of  the  disease  in  certain  definite  organs  as  the 


DERMATOLOGICAL  CONGRESS  375 

lungs  or  kidneys.  In  such  instances  the  symptoms  closely 
resemble  those  of  tuberculosis  of  the  same  organs,  except  that 
the  symptoms  and  clinical  signs  appear  to  be  even  less  pro- 
nounced than  in  tuberculous  changes  of  equal  extent  and 
severity. 

Onset,  Course,  and  General  Symptoms. — In  nine  cases  (1,2, 
3,  4,  9,  12,  13,  17,  and  21)  subcutaneous  abscesses  or  local 
ulcers  were  the  first  definitely  recognized  manifestations  of 
the  disorder,  and  were  followed  in  the  course  of  days  or  weeks 
by  the  development  of  general  symptoms.  Evidences  of 
systemic  disturbance  preceded  the  appearance  of  local  lesions 
for  periods  varying  from  a  few  days  to  a  month  in  five  cases 
(3,  10,  n,  1 6,  and  19),  and  from  three  to  six  months  in  seven 
cases  (5,  7,  8,  14,  15,  20,  and  22).  In  Case  6,  the  patient  died 
after  about  six  months  of  a  systemic  disorder  pointing  to  in- 
volvement of  the  lungs  and  intestines  and  with  the  develop- 
ment of  but  a  single  abscess. 

The  general  symptoms  may  be  ushered  in  by  acute  febrile 
disturbances  (as  in  Cases  3,  10,  and  n);  by  symptoms  of  a 
"  cold"  (as  in  Cases  5,6,  and  19) ;  by  tonsillitis  and  pneumonia 
(in  Case  15).  In  fourteen  cases  the  general  symptoms  were 
gradual  and  insidious  in  their  development.  In  Case  3  there 
were  repeated  attacks  of  an  acute  febrile  condition  resembling 
pneumonia,  followed  in  a  few  days  by  the  appearance  of  sub- 
cutaneous nodes  and  abscesses.  In  several  other  cases,  similar 
though  less  pronounced  febrile  reactions  preceded  the  appear- 
ance of  each  new  crop  of  abscesses. 

The  course  of  the  disease  is  essentially  chronic,  though 
moderately  acute  exacerbations  and  remissions  may  occur. 
In  every  case  except  No.  4,  in  which  the  disorder  was  recog- 
nized early  and  the  patient  promptly  recovered,  gradually 
increasing  loss  of  strength,  with  emaciation,  has  been  recorded, 
together  with  an  irregular  temperature  ranging  from  normal 
or  subnormal  to  101°  or  103°.  Night  sweats  and  cedema  were 
features  in  a  number  of  cases.  Death  has  resulted  usually 
from  gradual  exhaustion  due  to  the  chronic  pyaemia  or  to 
the  general  dissemination  of  the  disease  through  various  organs 
and  tissues  of  the  body.  In  a  few  instances  a  fatal  termination 
has  been  hastened  by  the  rapid  and  extensive  destruction  of 


376  SIXTH  INTERNATIONAL 

tissue  in  the  lungs  (as  in  Cases  3  and  5),  or  in  the  lungs  and 
other  organs  (as  in  Cases  6,  19,  and  20).  The  duration  of  the 
disease,  aside  from  Case  4,  which  apparently  recovered  in  about 
six  weeks,  varied  from  four  to  six  months  in  four  cases  (6, 
12,  19,  and  20) ;  from  six  months  to  a  year  in  three  cases  (3, 
5,  and  9) ;  and  from  one  to  two  and  one-half  years  in  thirteen 
cases. 

Pulmonary  symptoms  have  been  present  in  many  of  the 
cases  but  have  almost  invariably  been  mild  during  the  early 
part  of  the  disease  and  limited  usually  to  cough  with  ex- 
pectoration or  a  feeling  of  discomfort  in  the  chest.  In  a  few 
cases  (as  in  3,  5,  7,  9,  and  19),  as  the  disease  progressed  these 
symptoms  became  much  more  pronounced,  with  blood-stained 
sputum.  Physical  findings  have  not  pointed  to  extensive 
involvement  of  the  lungs  except  in  a  few  cases  (9,  19,  and  20) 
toward  the  end.  With  one  or  two  exceptions  the  changes 
found  in  the  lungs  at  the  autopsy  were  much  greater  than 
were  indicated  by  the  symptoms  and  physical  signs.  Blas- 
tomycetes  were  demonstrated  in  the  sputum  in  Cases  7,  8, 
9,  12,  19,  and  21.  Laryngitis,  with  hoarseness  or  aphonia, 
was  a  persistent  symptom  in  Case  5,  and  to  a  lesser  degree  in 
two  or  three  other  cases. 

Gastro-intestinal  symptoms  were  noted,  chiefly  in  the 
form  of  diarrhoea,  in  Cases  6,  7,  8,  12,  and  14.  Blastomycetes 
were  demonstrated  in  the  faeces  in  Cases  7  and  1 2 .  Symptoms 
of  nephritis,  with  albumen  and  casts  in  the  urine,  were  recorded 
in  Cases  6,  7,  8,  9,  and  19.  Blastomycetes  were  demonstrated 
in  the  urine  (from  the  prostate)  in  Case  19. 

Where  blood  examination  is  mentioned,  more  or  less 
leucocytosis  is  recorded  (in  Cases  7,  8,  9,  13,  14,  16,  19,  and  21). 
Anaemia  was  noted  in  Cases  5,  8,  16,  and  19.  Blastomycetes 
were  obtained  in  culture  from  the  blood  in  Cases  i  and  19 
(they  were  demonstrated  in  sections  of  blood-vessels  in  Cases 
5 ,  8,  and  9) .  Some  enlargement  of  the  spleen  was  noted  in 
Cases  5  and  14;  of  the  liver,  in  Case  5. 

The  amount  of  pain  experienced  by  different  patients  varied 
widely.  With  some  it  was  very  moderate  in  both  superficial 
and  deep  lesions,  in  others  all  the  lesions,  and  especially  affected 
joints,  were  exceedingly  painful  and  sensitive. 


DERMATOLOGICAL  CONGRESS  377 

Description  of  Lesions. — The  abscesses  may  be  conveniently 
divided  for  the  purpose  of  description  into  two  groups,  the 
superficial  and  the  deep.  The  former  appear,  usually  in  con- 
siderable numbers  and  often  in  successive  crops,  in  different 
parts  of  the  body  as  pea-sized  or  larger,  moderately  firm  nodules 
in  the  subcutaneous  tissue.  The  overlying  skin  is  not  modi- 
fied at  first  and  many  of  the  nodes  in  the  beginning  can  be 
detected  only  by  palpation.  During  periods  varying  from 
ten  days  to  several  weeks  the  lesions  enlarge,  soften,  and 
rupture,  with  the  formation  of  fistulse,  open  abscesses,  or 
ulcers.  Occasional  nodes  will  undergo  resolution  and  disap- 
pear after  attaining  a  diameter  of  one-half  an  inch  or  more. 
Small,  unbroken  abscesses  contain  a  peculiar  glairy  muco-pus. 
As  the  abscesses  get  larger,  and  especially  after  rupture  and 
secondary  infection,  the  discharge  differs  little  if  any  from 
that  of  an  ordinary  abscess,  though  the  contents  of  most  of 
the  abscesses,  even  when  very  small,  are  tinged  more  or  less 
with  blood.  These  superficial  abscesses  are  always  multiple, 
from  three  or  four  to  a  dozen  or  more  being  present  at  almost 
any  period  of  the  disease.  Ninety- three  such  abscesses  or 
the  resulting  lesions  of  the  skin  were  counted  at  one  time  in 
one  patient  (Case  5).  The  deeper  abscesses  are  larger,  less 
numerous,  and  are  usually  associated  with  destructive  pro- 
cesses in  the  bones,  muscles,  and  other  deep  tissues.  Psoas, 
perinephritic,  abdominal,  thoracic,  and  retropharyngeal  ab- 
scesses of  large  size  are  on  record.  Superficial  abscesses 
at  the  time  of  rupture  vary  in  size  from  one-half  to  two  inches 
in  diameter.  From  some  of  the  deep  abscesses  many  ounces 
(in  one  instance  over  a  quart)  of  pus  have  been  evacuated. 

The  cutaneous  lesions  are  found  chiefly  in  the  form  of 
irregular,  ragged,  rather  superficial  ulcers,  and  have  a  soft 
base,  a  granulating  floor,  and  a  purulent  or  sanguine-purulent 
discharge  which  often  forms  bulky  crusts.  Some  of  the 
ulcers  acquire  a  fungoid  or  papillomatous  appearance,  in 
others  the  borders  are  slightly  elevated,  and  contain  miliary 
abscesses.  In  some  instances,  as  the  result  of  transformation 
of  one  of  the  above -described  ulcers  but  more  commonly  as 
the  result  of  infection  of  the  skin  with  the  secretions  from 
them,  there  are  formed  the  characteristic  lesions  of  cutaneous 


378  SIXTH  INTERNATIONAL 

blastomycosis.  These  are  elevated  patches  of  various  sizes, 
with  a  verrucous  or  irregular  papilliform  surface,  a  soft,  pus- 
infiltrated  base,  and  a  purplish-red,  sloping  border  in  which, 
with  the  aid  of  a  hand-glass  magnifying  from  two  to  six 
diameters,  the  characteristic  miliary  abscesses  can  be  detected. 

The  joints  or  the  tissues  immediately  about  them  were 
affected  in  eleven  cases  (7,  8,  9,  14,  15,  17,  18,  19,  20,  21,  and 
22).  In  some  instances  the  joint  showed  for  weeks  no  evi- 
dence of  disease  except  pain,  with  or  without  a  small  amount 
of  swelling.  In  others  the  inflammatory  symptoms  were 
more  pronounced,  and  in  two  cases  were  so  marked  that  a 
diagnosis  of  acute  articular  rheumatism  was  made.  Inflamma- 
tion and  caries  of  some  of  the  bones  were  recognized  clinically 
in  nine  cases  (i,  7,  8,  9,  13,  18,  19,  20,  and  22).  Spondylitis 
was  present  in  Cases  7,  8,  and  18.  The  eye  was  involved  in 
two  cases;  a  corneal  ulcer  in  Case  i,  and  partial  loss  of  vision 
in  one  eye  in  Case  20.  From  the  corneal  ulcer,  in  Case  i,  and 
from  the  vitreous,  by  aspiration,  in  Case  20,  pure  cultures  of 
blastomycetes  were  obtained.  Slight  or  a  moderate  local 
or  general  enlargement  of  the  lymph  glands  is  noted  in  six 
cases  (i,  4,  5,  7,  14,  and  19),  but  in  none  was  adenopathy  at 
all  prominent. 

DIAGNOSIS. — The  disease  in  its  various  manifestations  could 
be  confused  with  an  ordinary  pyaemia,  tuberculosis,  syphilis, 
nephritis,  or  articular  rheumatism.  When  abscesses  or  cu- 
taneous lesions  are  present,  it  is  a  simple  matter  to  establish 
the  diagnosis  by  the  examination  of  pus  or  tissue.  The  ad- 
dition of  a  one  to  ten  per  cent,  solution  of  potassium  hydrate 
to  the  specimen  will  make  the  double-contoured  capsule  of 
the  organism  stand  out  clearly.  When  the  parasites  are 
present  in  very  small  number,  they  can  be  more  easily  demon- 
strated in  tissue  by  allowing  fragments  to  disintegrate  in  the 
potassium  hydrate  solution  or  more  slowly  in  fifty  per  cent, 
alcohol.  The  organisms  when  present  are  easily  found  in  the 
sediment. 

In  most  of  the  cases  in  which  systemic  symptoms  preceded 
the  appearance  of  the  abscesses  there  were  indications  of 
pulmonary,  gastro-intestinal,  or  kidney  disease,  and  in  several 
blastomycetes  were  demonstrated  in  the  sputum,  fasces,  and 


379 

urine.  They  are  less  difficult  of  demonstration  either  in 
secretions  or  in  tissue  than  tubercle  bacilli.  In  every  case 
of  multiple  abscess  formation  with  symptoms  of  a  general 
pyaemia,  as  well  as  in  cases  of  what  appear  to  be  atypical 
tuberculosis,  the  possibility  of  infection  with  blastomycetes 
should  be  considered. 

TREATMENT. — The  treatment  of  systemic  blastomycosis 
has  been  on  the  whole  very  unsatisfactory,  but  it  is  probable 
that  if  the  diagnosis  can  be  made  early,  the  proper  employment 
of  potassium  iodide,  tonics,  and  hygienic  measures,  including 
possibly  a  change  of  climate,  would  give  much  more  favorable 
results.  This  statement  is  based  on  the  fact  that  nearly 
all  the  cases  of  cutaneous  blastomycosis  have  been  improved 
and  a  number  have  recovered  completely  under  the  influence 
of  potassium  iodide.  Furthermore,  in  Gilchrist's  case  (No.  4 
of  this  series) ,  the  nature  of  the  systemic  condition  was  recog- 
nized at  the  very  outset  owing  to  the  fact  that  it  had  been 
preceded  for  several  years  by  local  cutaneous  lesions,  and 
under  the  influence  of  potassium  iodide  the  patient  made  a 
prompt  recovery.  Nos.  "  B"  and  "  C"  of  the  doubtful  cases 
appended  to  this  series  also  made  good  recoveries  under  this 
treatment.  In  Herrick  and  Garvey's  case  (No.  13)  the  pa- 
tient did  not  improve  greatly  under  the  treatment,  which 
included  the  use  of  potassium  iodide,  while  in  Chicago,  and  her 
condition  was  considered  hopeless,  but  on  removing  to  Cali- 
fornia she  made  complete  recovery.  In  all  the  other  cases 
in  this  series  the  disease  was  well  advanced  and  the  patient 
very  much  reduced  in  strength  and  weight  before  beginning 
the  treatment.  The  hygienic  surroundings  were  also  un- 
favorable in  several  instances.  In  a  few  of  the  cases  the  use 
of  potassium  iodide  was  followed  by  decided  temporary  im- 
provement, but  in  the  majority  it  apparently  had  no  influence. 
It  is  probable  that,  as  in  some  cases  of  cutaneous  blastomycosis, 
large  doses  (half  an  ounce  or  more  daily)  may  be  required 
to  produce  any  effect.  The  use  of  sulphate  of  copper  in- 
ternally, as  suggested  by  Bevan,  is  worthy  of  trial,  though  it 
proved  of  no  benefit  in  two  or  three  cases  in  which  it  was  used. 

Local  lesions  should  be  treated  like  those  of  cutaneous 
blastomycosis,  with  local  antiseptics,  of  which  a  one  per  cent. 


380  SIXTH  INTERNATIONAL 

solution  of  sulphate  of  copper  is  one  of  the  best,  and  with  the 
X-rays. 

PROGNOSIS. — Of  the  twenty-two  patients,  two  have  re- 
covered (4  and  13);  fifteen  are  dead;  and  five1  (12, 15,  17,  21, 
and  22)  are  failing  rapidly  and  probably  can  live  but  a  few 
weeks.  The  prognosis  is  evidently  exceedingly  unfavorable, 
though,  as  suggested  under  the  head  of  treatment,  we  believe 
that  with  an  early  diagnosis  and  proper  treatment,  includ- 
ing good  hygienic  surroundings,  the  mortality  can  be  greatly 
reduced. 

SUMMARY. — Relation  of  Blastomycosis  to  Coccidioidal  Granu- 
loma:  A  series  of  eighteen  cases  have  been  reported,  chiefly  from 
California,  by  Wernicke,  Rixford  and  Gilchrist,  D.  W.  Mont- 
gomery and  Morrow,  Ophuls  and  Moffett,  and  others,  under 
the  name  of  Protozoic  Skin  Disease  or  Coccidioidal  Granuloma.2 
A  comparative  study  of  the  reports  of  these  eighteen  cases 
and  the  twenty-two  cases  of  blastomycosis  shows  that  the 
two  disorders  have  many  features  in  common,  but  with  a 
few  more  or  less  essential  points  of  difference.3 

The  following  features  are  common  to  both:  A  chronic 
infectious  process  characterized  by  the  formation  of  multiple 
abscesses,  nodules,  and  miliary  tubercles  which  involve 
practically  all  of  the  organs  and  tissues  of  the  body,  including 
the  skin,  subcutaneous  tissue,  muscles,  bones,  joints,  internal 
organs,  and  nerve  tissues ;  symptoms  simulating  closely  miliary 
tuberculosis  or  a  chronic  pyaemia;  multiformity  of  cutaneous 
lesions  which  may  be  primary  but  are  commonly  secondary 
in  origin;  a  marked  tendency  to  involve  joints;  progressive 
emaciation  and  loss  of  strength  with  death  usually  from  gradual 

1  Patients  21   and  22   died  in  October.     No  report  has  been  received 
regarding  the  condition  of  the  other  three. 

2  For  summaries  and  reviews  of  these  cases  see  Ophuls,  Journ.  Amer. 
Med.  Assn.,  1905,  45,  p.  1291;  and  King,  ibid.,  1907,  48,  p.  743.     Both  of 
these  men  discuss  the  relation  of  Coccidioidal  granuloma  to  blastomycosis,  but 
both  look  upon  the  latter  chiefly  as  a  local  disorder  and  make  the  statement 
that  but  one  case  of  blastomycosis  had  become  generalized,  Ophuls  thus 
overlooking  five  cases,  and  King  ten  cases  of  systemic  blastomycosis  that 
had  been  published  when  they  made  their  reports. 

3  Since  this  paper  was  read  an  article  has  appeared  by  Hektoen,  Journ. 
Amer.  Med.  Assn.,  1907,  49,  p.  1071,  in  which  the  relation  of  the  two  dis- 
orders is  ably  discussed. 


DERMATOLOGICAL  CONGRESS  381 

exhaustion.  In  gross  pathology  and  microscopic  anatomy 
they  both  resemble  tuberculosis,  but  differ  from  it  inasmuch 
as  in  both  blastomycosis  and  coccidioidal  granuloma  the 
organisms  are  pus-producers.  The  two  conditions  further 
resemble  each  other  and  differ  from  tuberculosis  in  the  results 
of  animal  experiments  in  which  subcutaneous  inoculations 
are  ineffective,  though  intraperitoneal  and  intravenous  in- 
oculations are  quite  uniformly  successful  in  reproducing  the 
disease.  The  infection  atrium  in  several  cases  of  both  series 
has  been  apparently  the  respiratory  tract. 

As  to  points  of  difference,  the  average  course  of  the  coc- 
cidioidal disease  appears  to  be  somewhat  shorter  and  there  is 
a  much  greater  tendency  to  extension  through  the  lymphatic 
channels  than  in  blastomycosis;  these  two  features  being  due 
apparently  to  the  fact  that  in  tissues  the  organisms  of  coc- 
cidioidal granuloma  multiply  by  endogenous  spore  formation, 
while  in  blastomycosis  they  proliferate  solely  by  budding. 
It  is  true  that  in  Cases  7  and  14  of  this  series  certain  cellular 
forms  suggested  strongly  endogenous  spore  formation,  but 
the  further  development  of  the  spore-like  bodies  could  not 
be  demonstrated.  In  cultures  the  organisms  of  both  series 
grow  as  mould  fungi,  showing  some  slight  differences  in  their 
gross  appearances,  which  may  or  may  not  prove  to  be  im- 
portant. Further  study  along  uniform  lines  of  investigation 
will  be  necessary  before  a  satisfactory  classification  of  the 
organisms  in  either  series  will  be  possible. 

Blastomycosis  and  coccidioidal  granuloma  are  undoubtedly 
closely  related  disorders,  much  more  closely  related  to  each 
other  than  is  either  to  tuberculosis.  It  may  be  that  further 
study  will  remove  the  one  fundamental  difference  between 
them — that  is,  the  behavior  of  the  organisms  in  tissue — and 
prove  the  conditions  to  be  but  varieties  of  the  same  process. 
Hyde  suggests  (Journ.  Cutan.  Dis.,  1907,  xxv.,  p.  34)  that 
the  recognized  differences  between  the  two  disorders  may 
be  due  wholly  to  climatic  influence.  On  the  other  hand,  it 
is  probable  that  there  may  be  several  varieties  of  blastomy- 
cetes  and  other  closely  related  fungi  which  are  capable  of 
producing  in  man  a  series  of  disorders  of  the  same  general 
clinical  and  pathological  type. 


382  SIXTH  INTERNATIONAL 

SUMMARY  OF  CASES 

i.  BUSSE  and  BUSCHKE  (Busse:  Centralbl.  f.  Bakt.  u.  Parasiten- 
kunde,  1894,  xvi.,  p.  175;  Virchow's  Archiv,  1896,  Bd.  146;  Die 
Hefen  als  Krankheitserreger,  Berlin,  1897.  Buschke:  Volkmann's 
Sammlung  klinischer  Vortrdge,  Chirurgie  Nr.  218,  1898;  "Die 
Blastomykose,"  Bibliotheca  medica,  Abteilung,  Dermatologie,  Stutt- 
gart, 1902). 

The  patient,  a  delicate  woman,  31  years  of  age,  the  wife  of  a 
shoemaker,  was  born  and  lived  in  Germany.  Since  early  girlhood 
she  had  had  repeated  attacks  of  glandular  swellings  in  the  neck 
and  axillae.  At  the  time  of  her  examination  most  of  the  palpable 
glands  were  slightly  enlarged. 

According  to  Busse,  the  disorder  under  consideration  began  as 
a  tumor  similar  to  a  gumma  or  softened  sarcoma  below  the  knee, 
though  Buschke  states  that  several  months  prior  to  the  tumor 
formation  acne-like  lesions  appeared  on  the  face  and  neck.  These 
lesions  underwent  necrosis  in  the  centre  and  formed  pea-sized 
or  slightly  larger  ulcers,  some  of  which  healed  spontaneously. 
Later  many  other  similar  ulcers  and  some  slightly  larger  appeared. 
These  ulcers  were  round,  with  sharply  defined,  ragged,  somewhat 
undermined,  slightly  infiltrated  wall-like  edges,  and  surrounded 
by  firm  and  livid  borders.  The  base  of  the  ulcer  was  soft;  the 
floor  covered  with  granulations  and  tenacious  reddish-gray  se- 
cretions. Subcutaneous  nodules  also  were  seen,  some  of  which 
developed  into  ulcers.  The  tumor  below  the  knee  formed  an 
abscess  which  extended  to  and  involved  the  knee-joint.  A  few 
months  later  an  abscess  formed  in  the  right  ulna  near  the  elbow, 
and  another  in  the  left  sixth  rib.  The  patient  developed  bron- 
chitis with  varying  temperature,  irregular  pulse,  and  died  of 
gradual  exhaustion,  a  little  more  than  a  year  after  the  appearance 
of  the  abscess  below  the  knee. 

A  double-contoured,  yeast-like  fungus  was  obtained  in  pure 
culture  from  the  different  abscesses,  the  cutaneous  lesions,  a 
corneal  ulcer,  and  the  blood;  it  could  not  be  demonstrated  in  the 
urine. 

At  the  necropsy,  granulation  foci  or  abscesses  were  noted  also 
in  the  lung,  left  kidney,  and  spleen.  Microscopic  tubercles  in  the 
lungs  contained  no  tubercle  bacilli.  From  all  these  areas  the 
yeast-like  fungus  was  isolated.  The  organism  developed  in  cul- 
tures by  budding  and  appears  to  have  corresponded  in  all  essen- 
tials to  the  organisms  seen  in  blastomycosis.  An  adventitious 
capsule  was  described  similar  to  that  recorded  in  the  Curtis  case 


DERMATOLOGICAL  CONGRESS  383 

(Case  2).  Animal  experiments  showed  the  organism  to  be  patho- 
genic for  white  mice,  guinea-pigs,  rabbits,  and  dogs,  and  demon- 
strated the  absence  of  tuberculosis  in  the  case. 

2.  CURTIS  (Annales  de  I'Inst.  Pasteur,  1896,  x.,  p.  449). 

The  patient  was  a  man,  20  years  old,  who  developed  rather 
rapidly  multiple  tumors  on  various  parts  of  the  trunk,  neck,  ex- 
tremities, and  groin.  Some  were  firm  and  the  skin  over  them 
intact ;  others  formed  abscesses  which  broke  and  discharged.  The 
tumors  were  myxomatous  in  character  and  many  were  composed 
almost  entirely  of  double-contoured  and  budding  organisms,  both 
intra-  and  extra-cellular.  The  patient  died  in  about  a  year  from 
meningitis  of  undetermined  nature. 

Cultures  of  the  organism  were  obtained  and  in  the  hands  of 
Anna  Stecksen  animal  experiments  were  successful,  inoculations 
in  white  rats  producing  miliary  tumors  in  the  pleura,  spleen, 
kidneys,  and  lungs,  from  which  the  organism  was  recovered. 

3.  MONTGOMERY -WALKER  (F.  H.  Montgomery:  Journ.  Cutan. 
Dis.,  1901,  xix.,  p.  38;  Walker  and  Montgomery,  Journ.  Amer.  Med. 
Assn.,  April  5,  1902). 

The  patient,  an  unusually  well  developed,  vigorous  man,  33 
years  of  age,  a  carpenter,  and  resident  of  Chicago,  came  under 
observation  in  August,  1894,  for  a  cutaneous  disorder  on  his  back. 
This  began  seven  years  before  as  a  pimple  on  the  site  of  an  infected 
scratch,  and  had  developed  to  form  a  large,  irregular,  elevated, 
verrucous  patch,  which,  for  want  of  a  better  diagnosis,  was  con- 
sidered a  very  unusual  form  of  verrucous  tuberculosis.  The  man's 
general  health  had  been  unaffected. 

Two  months  later  (October,  1894),  he  presented  a  sensitive 
point  on  the  ulna  near  the  elbow,  the  entire  joint  being  very  much 
swollen  and  red.  These  symptoms  disappeared  in  a  few  days. 
A  week  later  he  had  a  severe  chill  followed  by  five  days  of  high 
temperature  and  great  depression,  accompanied  by  the  appear- 
ance, just  below  the  left  scapula,  of  two  deep-seated,  globular, 
dull-red  swellings,  one-half  inch  and  one  inch  in  diameter.  They 
suggested  the  tumors  sometimes  seen  in  erythema  nodosum. 
One  lesion  healed,  leaving  a  pigmented  area;  the  other  gradually 
assumed  the  characteristics  of  the  original  cutaneous  lesion. 

During  the  next  six  months  he  had  seven  or  eight  similar 
attacks,  accompanied  by  the  appearance  of  subcutaneous  and 
cutaneous  lesions  on  the  back  and  face.  During  this  time  his 
general  health  deteriorated  greatly.  In  March,  1895,  ne  entered 
the  County  Hospital.  No  definite  systemic  disorder  could  be 


384  SIXTH  INTERNATIONAL 

detected  at  this  time.  Some  of  the  lesions  were  curetted  and 
cauterized.  Two  weeks  later  symptoms  of  pulmonary  disease  were 
recognized.  A  few  days  before  his  death,  forty-three  days  after 
the  operation,  a  clinical  diagnosis  of  acute  miliary  tuberculosis 
was  made. 

At  the  autopsy  the  lungs,  liver,  spleen,  and  kidneys  were 
found  to  be  studded  with  miliary  bodies,  and  the  diagnosis  of 
miliary  tuberculosis  was  accepted.  Five  years  later,  however, 
histological  study  of  the  infiltrated  areas  of  the  lungs  showed  the 
typical  structure  of  the  blastomycotic  nodule,  including  large 
numbers  of  budding  organisms.  Sections  from  the  cutaneous 
lesions  had  shown  the  characteristic  infiltration — with  giant  cells, 
miliary  abscesses,  epithelial  hypertrophy,  and  budding  organisms — 
of  cutaneous  blastomycosis. 

Cultures  were  not  made.  Several  guinea-pigs  inoculated  at 
different  times  with  tissue  from  the  cutaneous  lesions,  and  at  the 
time  of  the  autopsy  with  tissue  from  the  deep-seated  organs,  de- 
veloped no  tuberculosis.  Prolonged  search  over  several  hundred 
sections  disclosed  no  tubercle  bacilli,  except  possibly  four  or  five 
which  morphologically  and  in  staining  qualities  appeared  to  be 
identical  with  tubercle  bacilli,  but  were  found  in  a  small  abscess 
opening  on  the  surface  of  the  skin,  where  secondary  infection  could 
easily  have  occurred. 

4.     GILCHRIST  (Brit.  Med.  Journ.,  1902,  ii.,  p.  1321). 

The  patient  was  a  negro,  28  years  of  age,  and  acquired  the 
disease  while  serving  a  sentence  in  the  penitentiary.  In  July? 
1907,  he  noticed  a  pimple  or  small  boil  on  the  abdomen  and  a 
month  later  a  similar  lesion  appeared  in  the  right  loin.  Both  grad- 
ually increased  in  size  and  spread  to  form  superficial  ulcers.  These 
were  not  painful  but  never  showed  any  tendency  to  heal. 

About  four  years  later  subcutaneous  swellings  appeared  simul- 
taneously in  the  right  groin  and  right  breast.  These  were  painful, 
became  swollen  and  ruptured  in  three  or  four  weeks,  discharging 
a  thin  mucoid  pus.  About  two  weeks  later  an  egg-sized,  soft 
swelling  appeared  at  the  lower  end  of  the  spine,  and  a  soft  small 
swelling  occurred  in  the  axilla. 

At  this  time  the  patient  was  in  apparently  good  general  health, 
aside  from  a  systolic  heart  murmur  and  irregular  temperature 
varying  from  99°  to  101.5°.  There  was  some  adenopathy  in  the 
axillae  and  in  the  groins.  Of  the  original  ulcers,  one  about  9x16  cm. 
occupied  the  right  half  of  the  abdomen,  and  another  about  8  x  14 
cm.  extended  from  near  the  right  border  of  the  first  ulcer  over  the 


DERMATOLOGICAL  CONGRESS  385 

lumbar  region  to  the  back.  Both  showed  the  characteristic  borders 
with  miliary  abscesses,  and  other  features  of  cutaneous  blastomy- 
cosis.  The  man  recovered  in  about  six  weeks  under  treatment  with 
iodide  of  potassium. 

Pure  cultures  of  blastomycetes  were  obtained  from  an  unbroken 
abscess  in  the  back  and  from  other  lesions.  None  could  be  obtained 
from  the  blood.  A  dog  inoculated  with  pus  from  an  unbroken 
abscess  developed  characteristic  nodules  in  the  lungs. 

5.  ORMSBY-MILLER  (Journ.  Cutan.  Dis.,  1903,  xxi.,  p.  121. 
Further  report  on  Bacteriology  by  Otis  and  Evans,  Journ.  Amer. 
Med.  Assn.,  October  31,  1903). 

The  patient,  aged  56,  was  a  Swede,  resident  of  Chicago,  and  a 
machinist  by  occupation.  For  several  years  he  had  lived  over  a 
stable.  He  was  never  robust,  and  for  ten  years  had  been  rather 
feeble.  In  April,  1902,  he  caught  cold  which  settled  in  his  chest; 
he  coughed  considerably,  had  scanty  expectoration  streaked  with 
blood,  and  became  so  weak  he  was  forced  to  stop  work.  In  July 
and  August  he  had  lesions  on  the  nose  and  thigh,  which  healed 
under  treatment. 

In  September,  he  entered  the  hospital,  badly  emaciated,  com- 
plaining of  a  severe  and  persistent  pain  in  the  back.  Physical 
examination  disclosed  no  cardiac  or  pulmonary  disease;  blood 
examination  showed  anaemia;  urine  was  normal. 

In  October,  when  the  case  came  under  the  observation  of  Dr. 
Hyde  and  the  writers,  subcutaneous  nodules,  which  softened,  rup- 
tured, and  formed  ulcers,  had  appeared  on  the  right  arm  and  both 
legs.  From  this  time  successive  crops  of  similar  lesions  appeared 
at  short  intervals  on  different  parts  of  the  trunk,  face,  and  limbs, 
as  many  as  ninety-three  being  present  at  one  time,  while  at  death 
the  entire  body  surface  was  covered  with  lesions  in  varying  stages 
of  development  and  involution.  They  appeared  first  as  pea-sized 
or  larger  nodules,  set  deep  in  the  hypoderm,  and  could  be  detected 
only  by  palpation.  As  they  increased  in  size,  approached  the  sur- 
face, and  softened,  the  color  of  the  skin  passed  through  varying 
shades  of  dark  red,  blue,  and  even  black.  The  abscesses  thus 
formed  eventually  ruptured,  discharged,  and  formed  unhealthy- 
looking  ulcers  of  various  sizes.  The  majority  of  these  ulcers  had 
ragged,  irregular  edges,  necrotic  floors,  soft  bases,  and  a  purulent 
and  hemorrhagic  discharge,  which  often  dried  to  form  heavy  crusts. 
But  one  only  of  these  ulcers  assumed  the  characteristics  of  cu- 
taneous blastomycosis.  The  patient's  general  health  deteriorated 
rapidly,  his  temperature  ranging  from  100°  to  103°,  his  pulse  being 


386  SIXTH  INTERNATIONAL 

rapid  and  feeble.  A  month  after  entering  the  hospital  there  were 
bronchial  breathing  and  other  signs,  which  gradually  grew  more 
pronounced,  of  pulmonary  involvement.  There  were  moderate 
general  adenopathy  and  slight  oedema  of  the  legs.  Toward  the 
end  the  patient  became  drowsy  and  at  times  comatose.  He  died 
December  4th,  about  eight  months  after  the  beginning  of  his 
disease. 

The  autopsy  showed  characteristic  blastomycotic  nodules  and 
infiltration  extensively  in  the  lungs,  which  were  almost  entirely 
destroyed,  and  in  the  spleen.  The  kidneys,  pancreas,  larynx,  and 
trachea  showed  the  same  type  of  lesions  but  in  smaller  numbers. 
The  histological  examination  showed  a  structure  characteristic 
of  blastomycosis,  including  the  parasites  in  immense  numbers. 
Portions  of  the  lung  tissue  seemed  to  have  been  almost  wholly 
replaced  by  the  parasites.  Amyloid  degeneration  was  present 
in  the  kidneys.  A  small,  deep-seated  subcutaneous  nodule  showed 
on  section  practically  no  change  in  the  overlying  epidermis,  with 
only  slight  changes  in  the  corium  proper,  consisting  of  vascular 
dilatation,  some  perivascular  infiltration,  oedema,  slight  degenera- 
tion of  the  collagen,  and  in  places  a  small  amount  of  cell  infiltration. 
The  infiltration  was  limited  almost  entirely  to  the  subcutaneous 
tissue  and  occurred  chiefly  in  the  form  of  fairly  well-defined  zones. 
The  characteristic  structure  consisted  of  a  collection  of  the  or- 
ganisms, of  leucocytes,  especially  polymorphonuclear,  and  red 
blood  cells,  around  which  were  seen  giant  cells,  connective  tissue- 
and  plasma  cells.  In  places  the  component  parts  of  the  infiltration 
were  more  or  less  intermingled. 

Pure  cultures  of  the  organisms  were  obtained  repeatedly  from 
cutaneous  and  subcutaneous  lesions,  and  after  death  from  the 
liver,  spleen,  kidneys,  and  from  beneath  the  pleura.  Inoculated 
guinea-pigs  developed  local  lesions,  and  characteristic  nodules 
in  the  liver  and  spleen  (of  one  pig),  from  which  the  organism  was 
recovered.  One  of  the  physicians  attending  the  autopsy  was 
accidentally  inoculated  on  his  finger,  on  which  there  appeared 
later  a  lesion  characteristic  of  cutaneous  blastomycosis. 

Tuberculosis  as  a  complication  was  absolutely  excluded  by 
the  failure,  after  careful  search,  to  find  tubercle  bacilli  either  in 
the  sputum  or  in  any  of  the  tissues  of  the  patient,  by  the 
failure  of  the  patient  to  react  to  the  tuberculin  test,  and  by 
the  fact  that  of  the  ten  guinea-pigs  and  two  rabbits  inoculated 
with  tissue  from  the  patient  none  developed  any  symptoms  of 
tuberculosis. 


DERMATOLOGICAL  CONGRESS  387 

6.  CLEARY  (Medicine,  November,  1904). 

The  patient,  a  man,  23  years  of  age,  Italian,  resident  of  this 
country  three  years,  entered  the  County  Hospital  in  May,  1903, 
giving  a  history  of  a  cold  and  diarrhoea  of  several  months' 
duration.  He  had  a  severe  cough  with  mucopurulent  expec- 
toration, had  lost  twenty-five  pounds,  and  was  extremely 
weak. 

Examination  showed,  immediately  above  the  right  sterno- 
clavicular  articulation,  an  opening  to  a  sinus  from  which  a  small 
amount  of  pus  escaped.  The  physical  signs  were  suggestive  of 
disease  of  the  apex  of  the  right  lung,  but  the  respirations  were 
normal  and  no  tubercle  bacilli  could  be  demonstrated  in  the  sputum. 
The  spleen  was  palpable;  his  feet  and  legs  were  slightly  cedematous. 
The  urine  showed  constantly  marked  albuminuria  with  abundant 
hyaline  and  granular  casts.  His  temperature  remained  subnormal, 
his  pulse,  rapid  and  weak,  and  he  died  nine  days  after  entering 
the  hospital.  The  clinical  diagnosis  was  nephritis. 

The  autopsy  showed  no  cutaneous  or  subcutaneous  lesions 
except  the  sinus  in  the  neck  which  communicated  with  a  small 
abscess.  Numerous  pin-head  to  pea-sized  gray  or  yellow  nodules, 
with  softened,  usually  necrotic,  centres  from  which  whitish  pus 
could  be  expressed,  were  found  abundantly  in  the  lungs,  and  in 
smaller  numbers  and  of  smaller  size  in  the  kidneys,  adrenals,  and 
liver.  Microscopic  lesions  were  found  also  in  the  myocardium 
and  spleen.  There  were  a  chronic  parenchymatous  nephritis, 
atrophy  of  the  heart,  fibrous  obliterative  pleuritis,  laryngitis, 
tracheitis,  and  bronchitis.  The  histological  structure  of  the 
nodules  was  characteristic  of  blastomycosis,  including  the  presence 
of  budding  organisms.  The  spleen,  kidney,  and  adrenals  showed 
marked  evidence  of  amyloid  disease.  The  cause  of  death  was 
evidently  a  generalized  infection  with  blastomycosis  and  a  rather 
extensive  amyloid  disease. 

No  cultures  were  taken. 

7.  EISENDRATH-ORMSBY  (Journ.  Amer.  Med.  Assn.,  October 
5,   1905.     With  further  history  and  autopsy  record  by  LeCount 
and  Meyers;  Journ.  of  Infect.  Dis.,  1907,  iv.,  p.  187). 

The  patient,  a  Polish  laborer,  33  years  of  age,  stated  that  his 
present  disease  began  in  February,  1904,  with  a  feeling  of  discom- 
fort in  the  right  side  of  the  chest.  About  four  months  later  cu- 
taneous lesions  appeared,  and  gradually  increased  in  size,  below 
the  left  ankle.  These  were  followed  at  short  intervals  by 
other  lesions  on  the  cheeks,  forearms,  face,  chin,  and  neck.  In 


388  SIXTH  INTERNATIONAL 

November,  he  developed  great  muscular  weakness  and  marked 
swelling  of  the  feet  and  ankles. 

On  admission  to  the  hospital,  in  February,  1905,  he  was  very 
much  emaciated,  anaemic,  and  exceedingly  weak;  with  moderate 
temperature,  marked  oedema  of  the  face  and  extremities,  clubbed 
nails,  some  inguinal  adenopathy,  bronchial  breathing,  dulness 
of  the  right  upper  lobe,  absence  of  lung  expansion,  and  other 
slight  evidences  of  more  extensive  involvement  of  the  lungs.  The 
urine  contained  albumen  and  casts;  budding  blastomycetes  were 
demonstrated  in  the  sputum  (the  first  case  in  which  this  demonstra- 
tion was  made) ;  there  were  a  number  of  subcutaneous  nodules  and 
superficial  ulcers  with  but  little  induration  and  considerable 
sanguino-purulent  discharge.  The  edges  of  the  ulcers  were  slightly 
elevated  and  surrounded  by  a  bluish-red  halo  in  which  were  a  few 
miliary  abscesses.  Some  of  the  lesions  were  more  or  less  papil- 
lomatous.  After  four  months  of  treatment  with  potassium  iodide 
internally,  and  with  radiotherapy,  antiseptic  dressings,  and  sur- 
gical interference  locally,  the  man  improved  greatly.  After  leaving 
the  hospital  and  neglecting  treatment  he  became  worse,  and  re- 
turned to  the  hospital  in  September  with  all  symptoms  exaggerated 
and  with  a  dorsal  spondylitis.  Further  developments  included: 
ankylosis  of  both  knees,  which,  with  the  left  elbow,  were  enlarged 
and  tender  but  showed  no  redness  or  elevation  of  temperature; 
oedema;  moderate  general  adenopathy;  a  diarrhcea  with  muco- 
purulent  discharge,  blood,  and  budding  blastomycetes  in  the  faeces. 
There  was  slight  leucocytosis ;  temperature  varied  from  normal 
to  103°.  The  patient  died  in  a  convulsion  August,  1906,  two  and 
one-half  years  after  the  beginning  of  the  disorder. 

The  autopsy  showed:  " Blastomycotic  broncho-pneumonia; 
blastomycosis  of  the  peribronchial  lymph  nodes,  of  the  pleura,  the 
subpleural,  and  retropharyngeal  tissue,  the  liver,  the  kidneys,  the 
colon,  the  spinal  column  (dorsal  vertebras),  the  external  spinal 
dura,  the  cerebellum,  the  left  elbow,  both  knee  and  ankle  joints, 
and  of  the  skin  and  subcutaneous  tissue  with  ulcerations,  fistulas, 
and  scars.  Fibrous  induration  at  root  of  right  lung.  Fibrous 
pleuritis.  Passive  hyperaemia  of  liver  and  spleen.  Serous  atrophy 
of  adipose  tissue.  Emaciation.  Adenoma  of  thyroid  and  accessory 
spleen."  (Characteristic  lesions  were  discovered  in  the  cerebrum 
after  the  report  of  the  case  was  published.) 

Histological  examination  demonstrated  the  typical  nodules 
of  granulomatous  tissue  with  necrotic  centres,  giant  cells,  and 
budding  organisms  in  the  lungs,  peribronchial  lymph  glands,  pleura, 


DERMATOLOGICAL  CONGRESS  389 

and  kidneys.  The  authors  believe  that  in  the  cerebellum  they 
found  an  area  in  which  the  organisms  multiplied  by  endosporula- 
tion.  They  did  not,  however,  demonstrate  the  intermediate 
stages  of  development  between  the  supposed  spores  and  mature 
organisms. 

Blastomycetes  were  demonstrated  in  the  sputum,  and  in  pus, 
and  obtained  in  pure  culture  from  subcutaneous  abscesses. 

No  tubercle  bacilli  could  be  found  in  pus,  sputum,  or  tissue, 
and  guinea-pigs  inoculated  with  pus  and  tissue  did  not  develop 
tuberculosis. 

8.     BASSOE  (Journ.  of  Infect.  Dis.,  1906,  iii.,  p.  91). 

The  patient,  a  boy  17  years  of  age,  a  native  of  Chicago,  entered 
the  service  of  Dr.  Senn  at  the  Presbyterian  Hospital,  July  26,  1904. 
Four  months  prior  to  this  date,  he  slipped  and  fell,  injuring  the 
right  shoulder  which  became  painful  and  swollen.  For  some  time 
previous  to  this  accident  he  had  pain  through  the  lumbar  region 
and  a  "gnawing"  sensation  in  the  upper  part  of  the  right  lung. 
He  had  a  cough,  low  fever,  night  sweats,  and  had  lost  thirty  pounds 
in  weight.  The  urine  was  normal.  July  26th,  from  a  large  abscess 
over  the  right  scapula  an  ounce  of  slightly  bloody  pus  was  removed 
with  a  trocar.  August  gth,  a  large  abscess  in  the  right  lumbar 
region  was  incised  and  a  pint  of  pus  evacuated.  During  the 
following  two  months  a  daily  rise  in  temperature  to  100°  and  101° 
was  noted.  On  September  ist,  a  blood  count  showed  4,180,000 
erythrocytes,  and  19,500  leucocytes.  November  i5th,  the  patient 
left  the  hospital  improved  but  was  readmitted  on  December  i8th. 
The  abscesses  had  refilled;  temperature  varied  from  100°  to  103°; 
nausea,  vomiting,  and  diarrhoea  were  present  at  times.  Blood 
count  in  January  showed  marked  anaemia,  hemoglobin  50  per  cent. 
In  May,  the  urine  showed  large  quantities  of  albumin  with  casts. 
During  the  last  two  months  of  the  patient's  life,  diarrhoea  was 
constant.  The  limbs  became  cedematous  and  painful.  There 
was  also  considerable  pain  in  the  abdomen;  irregular  fever  per- 
sisted, and  emaciation  increased.  Patient  died  June  27,  1905, 
approximately  fifteen  months  after  the  apparent  beginning  of  the 
disease. 

The  autopsy  and  histological  examination  showed:  "Chronic 
subcutaneous  blastomycotic  abscesses  in  right  scapular  region  and 
in  loin;  abscess  and  sinus  walls  made  up  of  vascular  granulation 
tissue  rich  in  polymorphonuclear  leucocytes,  mast  cells,  and 
blastomycetes.  Blastomycotic  caries  of  fourth  and  fifth  lumbar 
vertebrae,  with  bilateral  psoas  abscesses.  Disseminated  bias- 


390  SIXTH  INTERNATIONAL 

tomycotic  broncho-pneumonic  foci  in  both  lungs.  Areas  of  necrosis 
with  Langhans  giant  cells  in  the  mediastinal  glands.  Amyloid 
degeneration  of  spleen,  liver,  adrenals,  retroperitoneal,  mesen- 
teric,  and  mediastinal  lymph  nodes,  kidneys,  and  colon.  Bilateral 
fibrinous  pleuritis  and  mild  sero-fibrinous  peritonitis.  Chronic 
parenchymatous  nephritis.  Atrophy  of  the  heart.  Pulmonary 
oedema.  (Edema  of  feet  and  thighs.  Tigrolysis  of  ganglion  cells 
of  cerebral  cortex  and  ventral  horns  of  cord  (only  cervical  portions 
of  latter  examined)."  The  striking  features  were  the  extensive 
amyloid  degeneration  and  the  large  number  of  lesions,  containing 
organisms,  in  the  bones. 

Blastomycetes  were  found  repeatedly  in  pus  from  the  various 
subcutaneous  abscesses,  and  in  the  sputum,  but  could  not  be 
demonstrated  in  the  faeces.  Cultures  were  obtained ;  inoculated 
animals  developed  blastomycotic  lesions  (details  not  given  in 
report).  Tubercle  bacilli  could  not  be  found  in  pus,  sputum,  or 
tissue,  and  inoculated  guinea-pigs  did  not  develop  tuberculosis. 

9.     IRONS-GRAHAM  (Journ.  of  Infect.  Dis.,  1906,  iii.,  p.  666). 

The  patient,  a  German,  47  years  old,  had  worked  for  a  number 
of  years  in  a  Chicago  lumber  yard.  In  March,  1905,  a  small  sub- 
cutaneous nodule  appeared  on  the  inner  surface  of  the  right  thigh, 
increased  in  size  to  that  of  a  small  hen's-egg,  softened,  broke,  dis- 
charged a  bloody  pus,  and  slowly  healed,  leaving  an  indurated 
reddish-brown  scar.  Other  similar  lesions  appeared  in  rapid 
succession  on  the  legs,  hips,  arms,  and  face.  Later,  lesions  ap- 
peared over  the  ankles,  which  became  swollen,  red,  and  tender, 
interfering  greatly  with  walking.  Systemic  symptoms  were 
limited  to  a  slight  fever  and  to  gradually  increasing  weakness. 

On  September  nth,  when  admitted  to  the  Presbyterian  Hos- 
pital, he  was  weak  and  anaemic,  but  examination  detected  no  disease 
of  the  thorax  or  abdomen.  Scars,  partially  healed  ulcers,  sub- 
cutaneous nodes,  and  abscesses  were  present  on  the  forehead  and 
limbs.  The  superficial  lesions  began  as  small,  hard,  subcutaneous 
nodes,  which  gradually  softened,  broke  through  the  skin,  and 
discharged  bloody  pus  in  which  were  a  large  number  of  blastomy- 
cetes.  Other  abscesses  were  larger  and  deeper,  some  of  them  being 
subperiosteal  in  origin.  There  was  a  tendency  in  the  deeper 
lesions  to  extensive  dissection  along  the  intermuscular  fascia. 
Abscesses  which  had  ruptured  spontaneously  formed  ulcers,  having 
an  irregular,  granulating  floor,  and  rather  ragged,  slightly  raised 
edges  in  which  an  occasional  miliary  abscess  could  be  seen,  such 
as  are  common  in  the  lesions  of  cutaneous  blastomycosis.  The 


DERMATOLOGICAL  CONGRESS  391 

ulcers  were  surrounded  by  dull  red  or  purplish  zones  and  weer 
often  covered  by  dry,  hard  crusts.  Resulting  scars  were  usually 
slight  in  comparison  with  the  extent  of  the  preceding  ulcers.  Ab- 
scesses which  were  incised  and  evacuated  early  healed  without 
formation  of  the  above  described  ulcers.  After  a  short  period 
of  improvement  the  patient  developed  pain  in  the  chest,  cough 
with  muco-purulent  expectoration  often  streaked  with  blood,  and 
physical  signs  indicating  consolidation  of  the  upper  portions  of 
both  lungs.  The  patient  grew  steadily  weaker,  new  lesions  ap- 
peared over  the  body,  and  toward  the  end  there  was  marked 
destruction  of  subcutaneous  tissue  with  consequent  undermining 
of  the  skin,  and  at  several  points  bone  was  completely  denuded. 
Temperature  varied  from  normal  to  102°.  He  had  constant  leuco- 
cytosis  varying  from  12,500  to  21,200.  The  urine  showed  slight 
albuminuria  with  occasional  casts.  Patient  died  January  18, 
1906,  ten  months  after  the  appearance  of  the  first  lesions. 

The  autopsy  showed:  "Miliary  blastomycosis  of  lungs  and 
spleen ;  ulcerative  blastomycosis  of  the  upper  lobe  of  the  left  lung ; 
multiple  subcutaneous  abscesses  and  sinuses  involving  the  face, 
scalp,  and  all  the  extremities;  retro-cesophageal  abscess  with  erosion 
of  the  bodies  of  the  seventh  cervical  to  the  fifth  dorsal  vertebrae 
(inclusive)  and  of  the  anterior  surfaces  of  the  vertebral  extremities 
of  the  second  to  the  fifth  left  ribs;  erosion  of  left  parietal  bone; 
sloughing  deep  ulcer  of  the  right  thigh ;  abscess  of  thyroid  cartil- 
age ;  subpleural  hemorrhages  of  right  lung;  bilateral  fibrous  pleuritis ; 
hyperplastic  splenitis;  hyperplasia  of  mesenteric  lymph  glands; 
brown  atrophy  of  the  heart ;  colloid  goitre  (all  lobes) ;  slight  sclerosis 
of  anterior  mitral  leaflet  and  root  of  aorta ;  chronic  gastritis ;  localized 
fibrous  peritonitis;  chylous  ascites  (slight);  slight  atrophy  of  liver; 
retention  cysts  of  left  kidney. " 

Histological  examination  of  lung  tissue  showed  characteristic 
nodules  with  necrotic  centres  containing  organisms  in  large  numbers. 
Serial  sections  proved  the  disease  to  be  a  broncho-pneumonia. 
Two  blastomycetes  were  seen  in  a  large  blood  vessel.  From  the 
retro-cesophageal  abscess  giant  cells  containing  blastomycetes 
and  other  cells  peculiar  to  this  granuloma  were  demonstrated. 
The  spleen  showed  areas  of  necrotic  tissue  with  blastomycetes 
but  no  giant  cells.  Colloid  changes  were  present  in  the  thyroid. 

Cultures  of  the  organism  were  obtained  from  the  subcutaneous 
abscesses,  sputum,  and  kidneys  (though  smears  and  sections  made 
from  the  kidney  did  not  show  the  organism).  No  cultures  could 
be  obtained  from  the  blood  or  from  the  urine.  General  miliary 


392  SIXTH  INTERNATIONAL 

blastomycosis  was  produced  in  one  rabbit  by  inoculation  of  a 
pure  culture.  At  the  autopsy  the  streptococcus  pyogenes  was 
obtained  in  pure  culture  from  the  cerebro-spinal  fluid,  liver,  spleen, 
and  kidney,  the  staphylococcus  pyogenes  aureus  was  found  in  the 
liver  and  spleen,  and  in  pus  from  the  retro-oesophageal  and  knee 
abscesses. 

Tubercle  bacilli  could  not  be  found  in  the  sputum,  pus,  or 
tissue,  and  guinea-pigs  inoculated  with  pus  and  tissue  did  not 
develop  tuberculosis. 

10.  HEKTOEN-CHRISTIANSON  (Journ.  Amer.  Med.  Assn.,  1906, 
xlvii.,  p.  247). 

The  patient  was  an  Iowa  farmer,  28  years  of  age.  In  November, 
1904,  he  was  attacked  with  an  acute  fever  lasting  one  week,  during 
which  he  suffered  with  headache,  chills,  and  pain  in  the  back  and 
limbs.  At  the  end  of  the  second  week  numerous  spots  and  lumps 
appeared  on  the  face,  head,  neck,  hands,  forearms,  limbs,  and 
back.  Some  of  these  subsided  while  others  enlarged  and  formed 
indolent  ulcers.  Several  of  these  healed  leaving  atrophic  scars. 
In  June,  1905,  some  of  the  lesions  increased  in  size;  and  submaxil- 
lary,  supraclavicular,  and  other  abscesses  formed.  In  December, 
after  a  period  of  improvement,  all  the  lesions  became  much  worse. 

On  admission  to  the  hospital,  January  10,  1906,  there  were 
in  all  sixty  lesions  of  the  skin  and  subcutaneous  tissues.  There 
were  loss  of  weight  and  some  pulmonary  symptoms.  He  left  the 
hospital  April  6th,  somewhat  improved.  (We  are  informed  by 
Dr.  Hektoen  that  on  returning  home  new  lesions  continued  to 
appear,  and  that  the  patient  died  three  or  four  months  later  of  a 
sudden  paralysis.  There  was  no  autopsy.) 

Blastomycetes  were  obtained  in  pure  culture  from  the  ab- 
scesses and  were  demonstrated  in  sections  taken  from  the  ulcers. 
Neither  blastomycetes  nor  tubercle  bacilli  could  be  demonstrated 
in  the  urine  or  sputum. 

11.  HEKTOEN-CHRISTIANSON  (Journ.  Amer.  Med.  Assn.,  1906, 
xlvii.,  p.  247). 

The  patient  was  a  Norwegian  fanner,  58  years  of  age,  living 
in  Iowa.  There  was  a  marked  tuberculous  history  in  the  family. 
He  had  been  a  dipsomaniac  for  many  years,  but  always  healthy. 
In  January,  1905,  he  was  taken  with  an  acute  illness,  and  three 
weeks  later  a  large  abscess  formed  in  the  left  lumbo-dorsal  region. 
Later  there  was  another  attack  with  chills  and  general  debility, 
followed  in  a  short  time  by  swelling  under  the  skin  on  the  left 
forearm.  In  May,  red  spots.  2  cm.  in  diameter  and  suggesting 


DERMATOLOGICAL  CONGRESS  393 

ringworm,  appeared  over  the  right  thigh  and  forearm.  These  grew 
to  form  elevated,  granular  areas,  became  crusted,  and  had  an 
offensive  odor.  Some  of  the  ulcers  partially  healed  but  soon  formed 
again.  In  October,  painful  abscesses  appeared  on  the  right  arm 
above  the  elbow  and  on  the  left  forearm.  There  was  no  adeno- 
pathy.  There  was  slight  temperature  with  bronchial  rales.  (We 
are  informed  by  Dr.  Hektoen  that  death  occurred  in  the  early  part 
of  1907.) 

Histological  examination  of  the  ulcers  showed  the  character- 
istic structure  of  blastomycosis  and  the  organisms.  Blastomy- 
cetes  were  demonstrated  in  pus  and  obtained  in  pure  culture. 
Early  examination  of  the  sputum  was  negative,  but  later  it  was 
found  to  contain  tubercle  bacilli  but  no  blastomycetes. 

12.     COLEY-TRACEY  (Journ.  Med.  Res.,  1907,  xvi.,  p.  237). 

The  patient,  a  New  York  policeman,  27  years  of  age,  cut  his 
left  foot  on  a  clam  shell,  in  August,  1906,  producing  a  slight  wound 
which  healed  readily.  The  following  December  he  had  severe 
pain  in  the  lumbar  region  and  a  few  days  later  on  the  dorsum  of 
the  left  foot,  where  a  swelling  appeared,  softened,  and  discharged 
through  a  sinus  between  the  great  and  second  toes.  The  skin 
over  the  swelling,  though  tense,  was  not  red.  A  week  later,  similar 
lesions  appeared  on  the  dorsum  of  the  right  foot  and  thigh.  Above 
the  knee  two  small,  papillomatous,  crust-covered  tumors  appeared 
in  the  skin.  Many  other  subcutaneous  swellings,  varying  in  size 
from  that  of  a  hazel-nut  to  that  of  a  small  egg,  appeared  on  various 
parts  of  the  body,  chiefly  on  the  face,  arms,  and  thighs.  These 
tumors  softened  and  discharged,  forming  ulcers  or  elevated, 
crust-covered,  cutaneous  lesions.  With  the  tumors  appeared  a 
cough,  which  persisted  and  was  accompanied  by  emaciation 
and  loss  of  sixty  pounds  in  three  weeks.  The  man  made  no  improve- 
ment under  treatment  with  potassium  iodide  but  continued  to 
fail  in  general  health.  On  April  8th  he  had  sixty-five  tumors 
distributed  over  the  various  parts  of  the  body.  On  April  25th, 
many  more  had  developed  and  the  patient  was  failing  so  rapidly 
that  it  was  thought  he  could  not  live  more  than  one  or  two  weeks. 

Histological  examinations  showed  granulomatous  tissue,  giant 
cells,  with  double-contoured  and  budding  organisms.  Blastomy- 
cetes were  demonstrated  in  pus,  sputum,  tissue,  and  in  the  muco- 
purulent  discharge  from  the  rectum.  Pure  cultures  were  obtained. 
A  mouse  and  dog  were  inoculated  successfully.1 

»  Although  the  organisms  in  this  case  multiplied  in  tissue  and  pus  solely 
by  budding  and  never  by  endogenous  spore  formation,  the  author  classes 


394  SIXTH  INTERNATIONAL 

13.  HERRICK-GARVEY  (Preliminary report ,  Journ.  Amer.  Med. 
Assn.,  1907,  xlix.,  p.  328;  a  more  complete  report  is  in  preparation 
by  Dr.  A.  C.  Garvey.) 1 

The  patient,  a  married  woman,  24  years  old,  resident  of  Chicago, 
was  in  good  health  aside  from  certain  neurotic  and  hysterical 
tendencies. 

The  present  disorder  began  April  24,  1904,  with  "spots  like 
hives  and  pains  like  rheumatism"  over  the  left  gluteal  region. 
During  the  two  years  through  which  the  disorder  persisted  there 
appeared  seventy-nine  different  lesions,  varying  in  size  from  i  cm. 
to  8  cm.  or  more  in  diameter.  They  began  as  slightly  reddish  or 
purplish  spots  accompanied  at  times  with  an  infiltration  below  the 
skin.  They  gradually  became  larger,  tender,  and  formed  ab- 
scesses which  would  break  through  the  skin  and  discharge  a  thick, 
yellowish  pus.  A  few  underwent  spontaneous  resolution  without 
rupture.  Evacuation  of  the  pus  left  an  indolent,  granulating 
ulcer.  Extensive  undermining  of  the  skin  with  burrowing  of  pus 
occurred  in  places,  especially  over  the  left  gluteal  region,  where 
from  a  large  abscess  which  apparently  had  its  origin  in  the  pelvis 
a  quart  of  pus  was  removed.  In  some  of  the  lesions  bone  was 
destroyed.  The  scars  were  comparatively  slight  and  somewhat 
resembled  those  of  syphilis.  The  general  health  gradually  became 
impaired  after  the  first  few  weeks.  There  was  slight  temperature 
reaching  at  times  103°,  together  with  rapid  pulse,  haemic  murmur, 
cough,  and  at  times  evidences  of  slight  consolidation  of  the  right 
apex;  occasional  traces  of  albumen;  loss  of  weight;  anaemia;  low 
hemoglobin,  and  increase  in  leucocytes.  The  patient  was  neurotic 
and  hysterical,  slept  poorly,  and  complained  greatly  of  pain  at 
times.  She  was  treated  with  large  doses  of  iodide  of  potassium, 
tonics,  sedatives,  and  antiseptic  local  dressings.  In  February, 
1906,  she  went  to  California  but  slightly  improved.  She  lived 
largely  out-of-doors  and  gained  rapidly.  In  August,  1906,  the 
last  sore  disappeared,  and  July,  1907,  she  was  apparently  in  perfect 
health. 

it  with  cases  of  coccidioidal  granuloma  because  it  was  generalized,  and 
makes  the  statement  (evidently  taken  fron  Ophuls  and  Brown)  that  only 
one  case  of  blastomycosis  had  become  generalized.  At  the  date  of  his  re- 
port eleven  cases  (with  seven  autopsies)  of  generalized  systemic  blastomy- 
cosis had  been  published,  in  which  the  clinical  histories  and  the  organisms 
described  corresponded  closely  with  those  of  his  own  case. 

1  Dr.  Hyde,  to  whom  the  patient  was  referred  for  diagnosis  and  who 
saw  her  after  her  remarkable  recovery,  has  commented  on  the  influence  of 
climate  on  the  disease.  Journ.  Cutan.  Dis.  1907,  xxv.,  p.  34. 


DERMATOLOGICAL  CONGRESS  395 

Blastomycetes  were  repeatedly  demonstrated  in  pus  from  the 
subcutaneous  lesions,  from  some  of  which  Dr.  Ormsby  obtained 
pure  cultures. 

14.     MONTGOMERY  (Journ.  Cutan.  Dis.,  1907,  xxv.,  p.  393). 1 

The  patient  was  a  locomotive  engineer,  32  years  of  age,  in  fair 
general  health.  In  1902  and  1903,  while  running  a  locomotive 
through  a  swampy  region  in  the  South,  he  had  several  attacks, 
from  which  he  made  more  or  less  complete  recovery,  of  what  was 
considered  to  be  malaria.  From  January  to  April,  1903,  he  was 
unable  to  work,  being  weak  and  depressed,  and  suffered  from  pain 
in  the  chest  which  interfered  with  his  taking  a  deep  breath.  He 
spent  the  summer  in  the  North  and  apparently  recovered,  returning 
to  the  South  in  September.  In  November,  a  pea-sized  lump 
appeared  beneath  the  skin  on  the  right  cheek.  This  increased 
slowly  to  the  size  of  a  hazel-nut,  became  sensitive  and  inflamed, 
and  in  about  four  weeks,  broke  and  discharged  like  a  boil.  The 
resulting  ulcer  never  healed,  but  slowly  extended  peripherally. 
At  irregular  intervals  during  the  following  eight  months,  lesions 
appeared  on  the  lower  part  of  the  cheek,  on  the  right  jaw,  back 
of  the  right  ear,  and  under  the  chin.  These  all  began  as  small 
lumps  freely  movable  beneath  the  skin  and  in  from  two  to  six 
weeks  formed  painful  abscesses  which  ruptured,  forming  open  ulcers 
or  masses  of  infiltration  with  fistulous  tracts  leading  from  them. 
About  two  months  after  the  appearance  of  the  first  abscess  he  had 
an  attack  of  dropsy  which  lasted  about  ten  days.  At  this  time 
there  was  detected  in  the  sigmoid  region  a  peculiar  hard  mass,  for 
which  during  the  succeeding  three  months  the  patient  received 
a  number  of  injections  of  Alexander's  cancer  serum.  During 
this  treatment  he  lost  rapidly  in  weight,  but  after  its  suspension 
largely  recovered  his  general  health. 

On  examination  August  9,  1904,  he  presented  the  appearance 
of  a  man  in  fairly  good  general  health  except  that  he  was  under 
weight,  had  slight  emphysema  around  the  borders  of  the  lung, 
slight  enlargement  of  the  cervical  glands,  and  a  peculiar  firm  mass 
apparently  due  largely  to  muscular  resistance  in  the  sigmoid  area. 
On  the  right  cheek  were  two  irregularly  oval  ulcers  which  showed 
the  characteristic  elevated,  sloping,  dull-red  border  containing 
miliary  abscesses,  a  soft,  pus-infiltrated  base,  and  a  papillomatous 
surface.  Two  pea-sized  nodules  near  the  border  of  the  larger 
ulcer  were  due  evidently  to  inoculation  of  the  skin  from  secretion 

1  This  case  was  demonstrated  before  the  Chicago  Dermatological  Society 
in  April,  1905,  at  which  time  but  four  other  cases  had  been  reported. 


396  SIXTH  INTERNATIONAL 

from  the  ulcer.  A  similar  ulcer  was  located  back  of  the  right  ear. 
Smaller  ulcers  with  fistulous  tracts  leading  to  deep-seated  masses 
of  infiltration  were  located  under  the  right  jaw  and  under  the  chin. 

With  iodide  of  potassium  and  tonics  internally,  together  with 
antiseptics  and  the  X-ray  locally,  the  man  made  some  improvement, 
but  the  disease  was  never  completely  arrested.  In  January, 
1905,  he  became  weak,  emaciated,  and  cachectic,  with  irregular 
temperature  and  night  sweats.  A  general  examination  by  Dr. 
Joseph  Capps  disclosed  slight  dulness  of  the  apex  of  the  right  lung, 
some  enlargement  of  the  spleen,  and  a  leucocytosis  of  20,400.  The 
hard  mass  in  the  sigmoid  area  persisted,  there  were  subcutaneous 
nodules  near  the  symphysis  pubis,  and  bands  of  infiltrated  tissue 
along  Poupart's  ligaments,  most  marked  in  the  left  side.  The 
thighs  could  not  be  fully  extended. 

In  January,  new  subcutaneous  swellings  appeared  in  the  neck, 
breast,  groin,  foot,  and  elbow.  The  larger  joints  were  painful  but 
showed  no  evidence  of  inflammation.  He  had  an  irregular  tem- 
perature varying  from  100°  to  102°.  He  developed  no  new  pulmo- 
nary or  other  symptoms,  but  gradually  became  weaker  and  died 
August  29,  1905. 

The  autopsy  (Dr.  Peter  Bassoe:  opening  of  the  abdominal 
cavity  only  permitted)  showed  multiple  subcutaneous  abscesses 
with  formation  of  fistulous  tracts,  and  a  large  psoas  abscess  ex- 
tending into  the  thigh  and  connecting  through  a  fistula  with  an 
ulcer  in  the  left  groin.  Localized  adhesive  peritonitis  (chiefly 
periappendicitis  and  perihepatitis) ;  chronic  cervical  and  inguinal 
lymphadenitis. 

Histological  examination  showed  the  characteristic  blastomy- 
cotic  structure,  with  organisms,  in  the  lungs,  spleen,  appendix, 
and  inguinal  lymph  glands. 

Pure  cultures  of  blastomycetes  were  readily  and  repeatedly  ob- 
tained from  different  abscesses.  Nearly  every  tube  inoculated 
with  pus  from  an  unbroken  abscess  produced  a  pure  culture,  yet 
smears  of  pus  from  these  same  abscesses  showed  very  few  of  the 
organisms  of  the  usual  sizes  and  forms.  The  organism  was  un- 
usually pathogenic  for  guinea-pigs;  injection  into  the  abdominal 
cavity  of  a  pure  culture  being  in  each  instance  followed  by  ex- 
tensive systemic  infection,  with  the  formation  of  characteristic 
nodules  in  many  of  the  organs.  From  these  organs  the  parasite 
was  obtained  readily  in  pure  culture,  but  was  found  in  exceedingly 
small  numbers,  in  the  usual  forms,  either  in  smears  or  in  sections. 
The  number  of  organisms  thus  demonstrable  seemed  to  be  wholly 


DERMATOLOGICAL  CONGRESS  397 

insufficient  to  account  for  the  readiness  with  which  cultures  were 
obtained,  or  for  the  unusual  pathogenicity  of  the  organism  for 
guinea-pigs.  Pus  from  the  abscesses,  and  sections  of  tissue,  both 
from  the  patient  and  from  inoculated  guinea-pigs,  however,  showed 
large  numbers  and  masses  of  round  cells  about  the  size  of  a  red 
blood  corpuscle,  which  bore  a  strong  resemblance  to  small  blas- 
tomycetes,  though  the  double-contoured  capsule  and  other  definite 
structures  were  not  demonstrable.  The  large  number  of  these 
cells,  their  grouping,  and  their  uniform  size  suggested  multipli- 
cation by  sporulation,  but  no  relation  between  them  and  the  larger 
budding  forms  could  be  determined,  nor  could  large  bodies  con- 
taining spores  be  found.  The  unusual  activity  and  virulence 
of  this  organism  could  be  readily  explained  by  the  supposition 
that  in  this  case  the  parasite  existed  abundantly  in  pus  and  tissue 
in  small  forms  (the  result  probably  of  sporulation) ,  with  occasional 
larger  and  budding  bodies. 

15.     ORMSBY  (new  case). 

The  patient  was  an  Indiana  farmer,  38  years  of  age.  In  January, 
1902,  he  had  suppurative  tonsillitis  lasting  thirty -six  days  and 
terminating  in  pneumonia  which  confined  him  to  his  bed  for  seven 
weeks,  following  which  he  had  cough  with  moderate  expectoration. 
Beginning  April  25th,  he  was  confined  to  the  house  eight  weeks 
with  a  painful  swelling  in  the  left  knee-joint.  Another  swelling 
which  appeared  above  and  behind  the  knee  was  opened  and  pus 
removed.  Small  crusted  lesions,  which  when  opened  gave  exit 
to  dark  bloody  pus,  formed  on  the  dorsum  of  the  foot,  the  right 
hip,  the  back  of  the  right  hand,  and  the  face.  At  the  time  of  his 
examination,  July  31,  1903,  the  patient  was  pale,  anaemic,  had 
lost  much  weight,  and  was  very  feeble.  There  were  a  number  of 
cutaneous  and  subcutaneous  lesions  distributed  over  the  body 
beside  those  described  above.  The  cutaneous  lesions  all  began 
as  deep-seated  swellings  which  gradually  increased  in  size,  softened, 
and  discharged  pus.  After  several  months'  treatment  with 
potassium  iodide  and  radiotherapy  the  patient  showed  some  im- 
provement and  returned  to  his  home  in  Indiana.  The  last  report 
received  from  the  patient's  family  physician  was  in  May,  1904, 
twenty-five  months  after  the  beginning  of  his  disorder,  at  which 
time  the  man  was  not  expected  to  live  more  than  a  few  weeks. 

A  slightly  unusual  feature  in  this  case  is  the  fact  that  prac- 
tically all  the  cutaneous  lesions,  instead  of  as  in  most  instances 
a  few  of  them  only,  sooner  or  later  assumed  the  characteristic 
features  of  cutaneous  blastomycosis. 


398  SIXTH  INTERNATIONAL 

Blastomycetes  were  demonstrated  in  the  pus  and  secured  in 
pure  culture. 

1 6.  IRONS  (communication  from  Dr.  E.  E.  Irons,  of  an  un- 
reported  case.) 

Patient,  a  woman  20  years  of  age,  entered  the  Presbyterian  Hos- 
pital, November  8,  1905.  The  preceding  January  pains  appeared 
in  the  left  arm  and  shoulder  and  soon  after  in  the  right  leg.  A 
small  area  of  tenderness  developed  two  inches  below  the  knee. 
There  was  no  redness  or  tumefaction  at  first,  but  in  a  month  swell- 
ing appeared  and  gradually  extended  until  on  entrance  to  the 
hospital  it  occupied  the  entire  popliteal  region.  There  were  also 
small  swellings  on  the  back  and  in  the  right  lumbar  region,  and  a 
large  one,  two  inches  in  diameter,  in  the  left  interscapular  space. 
There  was  no  discoloration  or  pain  connected  with  the  lesions. 

On  admission  to  the  hospital,  physical  examination  disclosed 
nothing  further  than  a  few  signs  suggestive  of  pulmonary  disease. 
There  was  no  cough  or  expectoration  and  her  general  health  was 
only  slightly  impaired.  The  abscess  in  the  popliteal  region  rup- 
tured and  discharged  a  pint  of  bloody  pus.  On  enlarging  the 
opening  and  curetting  the  abscess,  a  sinus  was  discovered  which 
extended  upward  between  the  muscles  of  the  thigh,  and  appeared 
to  connect  with  an  abscess  near  the  pelvis.  Blood  count  was 
3,992,000  red  cells;  9500  leucocytes;  73  per  cent,  hemoglobin. 
Temperature  varied  from  99°  to  100°.  After  one  month's  treatment 
with  potassium  iodide  and  tonics  internally,  she  left  the  hospital 
unimproved  and  died  a  few  months  later.  No  autopsy  was  held. 

Blastomycetes  were  demonstrated  in  the  pus  from  the  ab- 
scesses, and  the  organism  was  grown  in  pure  culture. 

17.  HYDE-MONTGOMERY  (new  case). 

Patient  was  a  machinist,  24  years  of  age,  a  resident  of  Chicago. 
In  1899  the  great  toe  of  his  left  foot  was  amputated  for  what 
was  supposed  to  be  tuberculosis.  Three  weeks  later  severe  pain 
appeared  in  the  hip  and  persisted  for  three  months.  During  this 
period  a  deep  abscess  formed  in  the  middle  of  the  thigh,  opened, 
and  discharged.  He  also  had  pain  in  the  right  knee  followed  by 
the  formation  of  an  abscess  under  the  skin,  which  broke  after  two 
or  three  months,  leaving  an  ulcer  which  has  never  entirely  healed. 
During  this  period  of  activity  of  the  disease  he  had  some  fever, 
lost  a  great  deal  in  weight,  became  weak,  thinks  his  left  lung  was 
affected,  but  does  not  remember  having  had  cough  or  expectoration. 
After  the  first  few  months  his  general  health  gradually  improved 
and  the  only  lesion  was  the  persistent  ulcer  on  the  outer  surface 


DERMATOLOGICAL  CONGRESS  399 

of  the  right  knee,  which  after  attaining  the  size  of  a  silver  dollar 
remained  stationary  for  years. 

On  examination,  August,  1906,  the  outer  surface  of  the  knee 
showed  a  characteristic  area  of  cutaneous  blastomycosis.  At  this 
time  the  man  was  pallid  and  slightly  anaemic,  but  showed  no  other 
evidences  of  systemic  disease.  After  eight  months'  treatment 
with  the  potassium  iodide  internally,  radiotherapy,  copper  sul- 
phate and  other  antiseptics  locally,  the  patient's  general  health 
improved  and  the  local  lesion  nearly  disappeared.  In  July,  1907, 
his  general  health  had  again  decidedly  and  rapidly  deteriorated, 
and  the  knee  had  become  very  much  swollen  and  presented  a 
fistulous  opening  from  which  pus  escaped.  After  a  single  visit  to 
the  dispensary  he  disappeared  from  observation,  before  a  complete 
examination  could  be  made. 

Blastomycetes  were  demonstrated  in  smears  and  pure  cultures 
obtained  from  the  cutaneous  lesions  and  from  pus  in  the  fistulous 
tract. 

1 8.  OSWALD    (new  case  seen  by  one  of  us  [Ormsby],  at  the 
Alexian  Brothers'  Hospital,  through  the  courtesy  of  Dr.  Oswald 
and    Dr.    Louis    Schmidt.     The    following   notes    are    necessarily 
incomplete  and  it  is  hoped  that  at  a  future  date  the  case  will  be 
recorded  in  full). 

The  patient  was  a  man  with  a  cough  and  other  evidences  of  a 
grave  constitutional  disorder;  at  the  time  of  this  visit  he  was  very 
much  emaciated,  and  very  near  death.  There  were  cutaneous 
and  large  subcutaneous  lesions  on  the  face,  chest,  and  other  parts 
of  the  body,  and  several  joints  and  a  number  of  vertebrae  were 
affected.  On  our  visit  that  day  the  organism  of  blastomycosis 
was  demonstrated  in  the  sputum  and  in  pus  obtained  from  the 
knee  joint,  from  a  large  subcutaneous  abscess  on  the  chest,  and 
from  a  cutaneous  lesion  on  the  face. 

Shortly  after  this  the  patient  died,  the  autopsy  being  performed 
by  Dr.  W.  A.  Evans.  We  are  informed  that  blastomycotic  lesions 
occurred  generally  throughout  the  body,  and  that  the  bodies  of 
several  vertebrae  were  practically  destroyed,  together  with  some 
of  the  spinal  cord. 

Pure  cultures  were  obtained  by  Dr.  Jerger,  who  also  demon- 
strated the  pathogenicity  of  the  organism  for  guinea-pigs  and  the 
absence  of  tuberculosis  in  the  case. 

19.  KROST-MOES-STOBER  (new  case).1 

The  patient,  a  Polish  laborer,  and  resident  of  United  States 
1  We  are  indebted  to  Dr.  Stober  for  the  record  of  this  case,  and  to  Dr. 


400  SIXTH  INTERNATIONAL 

four  years,  entered  the  Cook  County  Hospital,  April  8,  1907.  The 
present  disorder  began  four  months  before,  as  a  severe  cold  with 
cough  and  expectoration,  followed  shortly  by  pain  in  the  back. 
A  month  later  a  swelling  appeared  on  the  dorsal  region  at  the  left 
of  the  median  line.  Cough  and  expectoration  increased;  the 
appetite  was  poor;  he  lost  in  weight;  and  at  the  end  of  six  weeks 
general  weakness  prevented  his  continuing  at  work.  Two  months 
after  the  beginning,  a  painful  swelling  developed  on  the  dorsum 
of  the  left  hand  and  foot,  and  over  the  left  eleventh  rib ;  a  warty 
growth  appeared  at  the  right  ala  of  the  nose,  followed  by  enlarge- 
ment of  both  submaxillary  glands. 

Examination  on  admission  revealed  in  addition  to  the  above 
findings:  anaemia;  dulness  over  the  left  lower  lobe;  bronchophony 
with  rales;  a  little  enlargement  of  the  heart;  inguinal  adenopathy, 
and  slight  temperature.  There  were  small  papillomatous  growths 
on  the  forehead  and  right  forearm.  Blastomycetes  were  demon- 
strated in  pus  from  the  subcutaneous  swellings,  in  the  sputum, 
and  in  the  urine,  which  showed  also  a  few  casts  and  leucocytes. 
(The  autopsy  showed  that  the  organisms  in  the  urine  came  from 
the  prostate  gland.)  Several  blood  counts  showed  leucocytes 
from  14,200  to  29,800,  with  hemoglobin  about  70  per  cent.  The 
patient  steadily  lost  strength;  pain  increased;  sputum  became 
more  abundant,  muco-purulent,  and  at  times  bloody;  there  was 
profuse  sweating,  and  new  abscesses  appeared  on  different  portions 
of  the  body..  The  patient  died  June  14,  1907. 

Autopsy  showed:  miliary  and  nodular  blastomycosis  of  the 
lungs,  kidneys,  spleen,  cerebrum,  pleura,  and  lymph  glands ;  ul- 
cerative  blastomycosis  of  the  cerebrum,  cerebellum,  prostate, 
pleura,  and  skin;  multiple  abscesses  of  the  osseous,  muscular,  and 
subcutaneous  tissues;  parenchymatous  nephritis;  fatty  changes, 
adenoma,  and  angioma  of  the  liver;  adenoma  of  the  thyroid; 
general  lymphatic  hyperplasia;  shaven  beard  appearance  of  Peyer's 
patches;  atrophy  of  the  testicles;  fibrous  pleuritis.  Some  of  the 
subcutaneous  abscesses  were  six  inches  in  diameter,  and  extended 
deep  into  the  muscular  tissue.  There  were  abscesses  limited  to 
bony  structures,  others  burrowed  into  surrounding  soft  structures. 
Erosions  and  more  deeply  seated  destructive  changes  occurred 
in  the  bones  of  the  hand  and  the  feet,  the  sternum,  ribs,  and  verte- 
brae. The  presence  of  large  numbers  of  myelocytes  in  the  blood 
led  the  reporters  to  the  belief  that  the  medulla  of  other  bones  was 

Simmons,  editor  of  the  Journ.  Amer.  Med.  Assn.,  where  it  is  to  be  published, 
for  allowing  us  to  abstract  the  article  for  this  review. 


DERMATOLOGICAL  CONGRESS  401 

probably  invaded.  The  deep  cervical  and  inguinal  glands  were 
much  enlarged;  the  superficial  cervical,  submaxillary,  and  axillary 
glands  were  slightly  larger  than  normal. 

A  histological  examination  of  the  affected  areas  in  the  bones, 
joints,  and  internal  organs,  including  the  cerebrum,  cerebellum, 
and  prostate  gland,  demonstrated  the  presence  of  blastomycetes, 
together  with  the  granulomatous  structure  usually  seen  in  blasto- 
mycosis. 

Pure  cultures  of  the  organisms  were  obtained  during  life  from 
the  blood,  various  abscesses,  and  cutaneous  lesions,  and  post 
mortem  from  the  knee  joint,  spleen,  and  pleura,  and  a  mixed  cul- 
ture from  the  prostate.  No  tubercle  bacilli  could  be  found  in  the 
sputum,  pus,  or  tissue. 

20.  CHURCHILL-STOBER  (to  be  reported  in  the  Cook  County 
Hospital  reports).1 

The  patient,  a  Polish  laborer,  39  years  old,  employed  for  the 
past  four  years  in  scrubbing  and  dusting  Pullman  cars,  entered 
the  Cook  County  Hospital,  May  14,  1907.  For  three  months  he 
had  suffered  pain  in  the  right  side  of  the  head  and  face,  most 
marked  over  the  malar  prominence.  Later,  pain  aggravated  by 
movement  appeared  in  the  right  hip  and  knee,  above  the  shoulders, 
and  in  the  left  wrist.  The  knee  and  wrist  became  very  much 
swollen  and  exceedingly  tender.  From  the  beginning  he  had  a 
moderate  cough  with  occasional  blood-stained  sputum.  There 
was  marked  loss  of  vision  in  the  right  eye. 

Examination  showed  the  patient  to  be  markedly  emaciated, 
twenty  pounds  under  his  average  weight;  his  temperature  101°,  with 
physical  signs  of  beginning  consolidation  of  the  upper  right  lobe. 
The  right  hip,  knee,  and  stemo-clavicular  joints  were  swollen, 
red,  and  painful.  Over  the  knee  there  was  fluctuation.  The  right 
great  toe  contained  an  abscess  which  discharged  thick,  blood-stained 
pus.  Scattered  over  the  body  were  numerous  pustular  lesions 
and  fourteen  subcutaneous  abscesses  (one  under  the  scalp) ,  varying 
in  size  from  one  to  five  centimeters  in  diameter.  The  conjunctiva 
of  the  right  eye  was  red  and  cedematous.  The  patient  was  given 
potassium  iodide  but  apparently  without  effect.  He  had  an 
irregular  temperature  with  profuse  sweats;  pulse  and  respiration 
were  rapid.  The  abscesses  slowly  enlarged  and  the  patient  died 
of  gradual  exhaustion,  June  20,  1907. 

Autopsy  showed:  Serofibrinous  pleuritis,  pericarditis,  purulent 

1  We  are  indebted  to  Dr.  Stober  for  notes  of  this  and  the  two  following 
cases. 

VOL.  i — *6 


402  SIXTH  INTERNATIONAL 

bronchitis,  parenchymatous  degeneration  of  the  kidneys  and  liver, 
fibroid  induration  of  the  lungs,  fibroid  pleuritis;  miliary  blastomy- 
cotic  nodules  of  the  lungs,  pleura,  kidneys,  spleen,  peribronchial 
lymph  glands;  multiple  blastomycotic  abscesses  of  the  lung, 
prostate,  and  the  osseous,  muscular,  and  subcutaneous  tissues;  mul- 
tiple blastomycotic  ulcers  of  the  skin ;  blastomycosis  of  the  right  eye. 

Pure  cultures  of  blastomycetes  were  recovered  from  the  vitre- 
ous humor  of  the  eye  by  aspiration.  Blastomycetes  were  also 
recovered  from  the  pericardial  fluid,  pleural  fluid,  and  various 
abscesses,  including  the  prostatic  abscess;  streptococci  were  re- 
covered from  the  heart  blood.  Blood  cultures,  as  well  as  ex- 
amination of  the  sputum  and  urine,  showed  neither  blastomycetes 
nor  tubercle  bacilli. 

21.  LEWISON-JACKSON  (to  be  reported  in  the  Cook  County 
Hospital  reports). 

The  patient,  an  Italian  boy,  aged  17  years,  an  organ  grinder 
and  machine-shop  helper,  entered  the  Cook  County  Hospital  May 
20,  1907.  Five  months  before  this  an  abscess  appeared  in  the 
middle  of  the  right  thigh,  ruptured  in  two  weeks,  and  discharged 
a  thick,  dark-brown  pus.  The  resulting  ulcer  soon  became  covered 
with  a  heavy  crust.  Two  months  later  the  right  knee-joint  became 
the  seat  of  pain,  limitation  of  motion,  and  later  of  swelling.  The 
following  month  the  left  knee  became  similarly  involved,  and 
subsequently  the  left  ankle,  both  elbows,  left  wrist,  and  the  first 
metacarpo-phalangeal  joint  of  the  left  hand.  One  month  after 
the  first  joint  symptoms,  subcutaneous  abscesses  and  crust-covered 
ulcers  began  to  appear  on  the  face  and  scalp. 

On  examination,  the  patient  was  found  to  be  anaemic,  poorly 
developed,  and  suffering  with  great  pain  and  stiffness  in  the  joints. 
Slight  changes  from  normal  were  detected  in  the  physical  ex- 
amination of  the  lungs.  Urine  practically  negative.  Blood: 
leucocytosis  9600,  cultures  negative.  Temperature  varied  from 
101°  to  103.6°;  respirations  and  pulse  both  rapid.  With  tonic 
treatment  and  potassium  iodide  great  improvement  occurred, 
and  he  was  discharged  July  8th,  but  was  readmitted  in  ten  days, 
with  a  sharp  recurrence  of  all  symptoms.  This  time  better  re- 
sults were  obtained  with  cupric  sulphate  used  both  locally  and 
internally,  and  on  August  i7th  he  was  discharged  a  second  time 
in  fairly  good  condition,  though  he  was  not  well  and  was  not  free 
from  cutaneous,  subcutaneous,  and  joint  lesions. 

Blastomycetes  were  demonstrated  in  the  abscesses,  also  later 
in  the  sputum.  Tubercle  bacilli  not  found. 


DERMATOLOGICAL  CONGRESS  403 

22.  MYERS-STOBER  (to  be  reported  in  the  Cook  County 
Hospital  reports). 

Patient,  20  years  of  age,  was  a  clerk  in  Chicago,  but  had  been 
some  months  before  employed  as  a  laborer  on  a  dredge  in  Arkansas 
and  Iowa.  Admitted  to  Cook  County  Hospital  May  8,  1907,  in 
the  service  of  Dr.  Ryerson.  For  four  months  he  had  been  ill, 
suffering  with  pain,  shortness  of  breath,  chills  and  fever,  and  oc- 
casional night  sweats.  For  a  month  he  had  pain  in  the  right  ex- 
ternal malleolus,  which  was  worse  at  night.  The  leg  had  become 
swollen  and  tender.  He  had  some  patches  on  the  face  which  he 
had  been  told  were  lupus  spots. 

On  examination  the  patient  was  seen  to  be  poorly  developed, 
anaemic,  and  emaciated.  There  were  some  evidences  of  consolida- 
tion of  the  lower  lobe  of  the  lung.  Temperature  was  normal; 
urine  examination  negative.  On  the  neck  was  a  large,  soft,  fluc- 
tuating mass.  A  large  number  of  reddish  areas  looking  as  though 
they  contained  pus,  and  abscesses  of  varying  sizes,  were  present 
on  different  parts  of  the  body.  The  right  external  malleolus  was 
swollen,  red,  tender,  and  painful.  Several  joints  were  similarly 
involved  but  to  less  extent.  On  opening  and  draining  the  swelling 
over  the  malleolus,  necrotic  bone  was  exposed.  The  patient 
slept  but  little,  complaining  of  pain,  especially  at  night.  His 
temperature  varied,  ranging  as  high  as  102.6°. 

Blastomycetes  were  demonstrated  in  pus  from  a  number  of 
unbroken  abscesses  and  were  obtained  in  pure  culture. 

PROBABLE  CASES 

(A)  HYDE-MONTGOMERY  (reported  as  a  case  of  cutaneous 
blastomycosis  in  Journ.  Cutan.  Dis.,  1901,  xix.,  p.  49). 

The  patient  was  a  male,  aged  47,  a  resident  of  Chicago  and  a 
sewer  builder.  At  the  time  this  case  was  reported,  large  areas  of 
cutaneous  blastomycosis  existed  upon  the  arms  and  forearms. 
Under  treatment  the  areas  nearly  disappeared  but  returned  on 
his  neglecting  treatment,  as  he  did  for  many  months  at  a  time. 
About  four  years  after  the  beginning  of  his  trouble  he  reappeared, 
after  a  long  absence,  with  much  more  extensive  and  severe  cu- 
taneous lesions  than  ever  before,  and  with  fever,  cough,  anorexia, 
and  marked  general  weakness,  the  symptoms  pointing  strongly 
to  systemic  infection  with  blastomycosis.  He  disappeared  from 
view  and  died  soon  after  in  the  poorhouse,  where  the  nature 
of  his  disease  was  not  recognized,  and  no  autopsy  was  obtained. 

(5)  HYDE-MONTGOMERY  (reported  as  a  case  of  cutaneous 
blastomycosis,  Journ.  Amer.  Med.  Assn.,  June  7,  1902). 


404  SIXTH  INTERNATIONAL 

The  patient  was  a  well-to-do  woman,  56  years  of  age,  and  a 
resident  of  Chicago.  In  November,  1901,  she  experienced  a  severe 
mental  shock.  Three  weeks  later  a  lesion  appeared  on  the  dorsal 
surface  of  the  left  hand,  and  within  two  weeks  other  lesions  appeared 
on  the  left  cheek,  left  heel,  right  leg,  right  big  toe,  right  foot,  and 
left  arm.  Some  of  these  began  as  "pimples,"  others  as  small 
nodules  deep  in  the  skin.  At  the  same  time  subcutaneous  nodes 
varying  in  size  from  that  of  a  bean  to  a  walnut  appeared  over 
different  portions  of  the  breast,  thorax,  and  left  thigh.  These 
subcutaneous  swellings  became  slightly  red  on  the  surface  and 
very  sensitive  to  the  touch,  but  gradually  underwent  resolution 
without  abscess  formation.  In  January,  lesions  appeared  on  the 
upper  lip  and  on  the  right  index  finger. 

The  cutaneous  lesions  were  characteristic,  clinically  and  his- 
tologically,  of  cutaneous  blastomycosis.  The  organisms  were 
demonstrated  and  recovered  in  cultures  from  the  lesions.  Under 
treatment  with  potassium  iodide  internally  and  radiotherapy 
locally,  the  patient  made  a  complete  recovery.  Looking  at  this 
case  in  the  light  of  recent  experience  it  is  highly  probable  that 
the  multiple,  somewhat  widely  disseminated,  subcutaneous  nodes 
were  blastomycotic  in  origin. 

(Q  HYDE-MONTGOMERY  (new). 

The  patient  was  a  successful  business  man  of  unusually  robust 
appearance,  58  years  of  age,  and  a  resident  of  Illinois.  In  October, 
1904,  he  caught  a  cold  accompanied  by  headache,  cough,  some 
expectoration,  soreness  in  the  chest,  and  general  weakness.  No- 
vember 1 7th  he  went  to  bed  and  called  a  physician  for  the  first 
time.  The  symptoms  suggested  a  possible  pneumonia.  Ten 
days  after  going  to  bed,  the  pain  in  his  chest  became  more  marked 
and  an  abscess  formed  which  on  December  4th  opened  just  below 
the  upper  border  of  the  sternum  and  discharged  a  large  quantity 
of  pus.  The  patient  slowly  recovered  his  health,  being  confined 
to  the  house  two  months.  On  examination  January  30,  1905, 
there  was  found  a  small  fistula  one  inch  in  length  lying  across 
the  sternum,  and  characteristic  lesions  of  cutaneous  blastomycosis 
on  the  right  cheek  and  on  the  dorsum  of  the  right  hand.  These 
appeared  at  first  as  lumps  beneath  the  skin  a  few  weeks  after  he 
began  to  feel  badly.  The  patient  stated  he  felt  fairly  well  but 
was  twenty  pounds  under  weight.  Examination  of  the  chest  by 
Dr.  Joseph  Capps  disclosed  signs  of  moderate  infiltration  of  the 
apex  of  the  right  lung. 

His    physician    reported    complete    recovery    after    two    and 


DERMATOLOGICAL  CONGRESS  405 

one-half  months  of  treatment  with  potassium  iodide  and 
radiotherapy. 

Blastomycetes  were  demonstrated  in  smears  and  obtained 
in  pure  cultures  from  the  miliary  abscesses  in  the  borders  of  the 
cutaneous  lesions. 

The  symptoms  and  course  of  his  illness,  his  recovery  under 
treatment  with  the  iodide  of  potassium,  and  the  subcutaneous 
origin  of  the  cutaneous  lesions,  all  point  strongly  to  its  having  been 
a  case  of  systemic  blastomycosis  from  which  the  patient  made  a 
full  recovery. 

(D)  ALBERS  (Transactions  of  the  Chicago  Pathological  Society, 
March  i,  1907). 

The  patient  was  a  Wisconsin  fanner,  64  years  of  age,  a  Scan- 
dinavian by  birth.  In  July,  1906,  he  began  to  suffer  from  pain  in 
the  chest  and  abdomen,  sore  throat,  cough,  dysuria,  anorexia, 
and  loss  of  strength.  He  was  emaciated;  his  pulse  was  weak  and 
irregular;  but  his  temperature  was  normal,  and  physical  findings 
relative  to  the  lungs  were  negative.  The  skin  lesions  are  de- 
scribed as  raised,  hyperaemic  spots,  or  pimples,  somewhat  larger 
than  an  ordinary  pimple,  scattered  over  the  body. 

Specimen  of  bloody,  tenacious  sputum  sent  to  the  laboratory 
for  examination  contained  no  tubercle  bacilli  but  many  blastomy- 
cetes.  The  organism  was  obtained  from  the  sputum  in  almost 
pure  culture. 

The  subsequent  history  of  the  patient  was  not  obtainable. 

(E)  EASTMAN-KEENE  (Annals  of  Surgery,  November,  1904). 
The  patient  was  a  woman  who  stated  that  she  had  suffered 

for  six  weeks  with  what  she  termed  "boils."  The  first  one  ap- 
peared as  a  small,  hard  lump  about  the  size  of  a  pea  on  the  back 
of  her  left  hand.  It  grew  to  the  size  of  a  small  pigeon-egg  and 
then  gradually  disappeared.  It  was  accompanied  by  no  sensations 
nor  was  there  any  discoloration  of  the  skin.  A  few  days  after 
this  had  disappeared  she  noticed  beneath  the  skin  near  the  elbow 
a  hard,  globular  body,  about  one  and  one-half  inches  in  diameter. 
This  at  first  was  similar  to  the  growth  on  the  back  of  the  hand, 
being  neither  painful  nor  discolored.  It,  however,  gradually 
increased  in  size  until  she  opened  it  with  a  needle  when  a  thin, 
grayish,  watery  substance  escaped.  Budding  blastomycetes  were 
found  in  the  discharge  which  had  persisted  up  to  the  time  of  her 
examination.  A  similar  lesion,  the  size  of  a  hen's  egg,  which 
later  broke  down  and  discharged,  was  present  in  the  axilla. 

The  patient  was  the  mother  of  a  girl  whom  Drs.  Eastman  and 


406  SIXTH  INTERNATIONAL 

Keene  had  been  treating  for  a  wound  that  was  the  seat  of  a  mixed 
infection  with  bacillus  pyocyaneus  and  blastomyces. 

The  mother  stated  that  her  son,  19  years  old,  had  at  the  same 
time  a  similar  lesion  on  his  hip.  A  small  kernel  appeared  beneath 
the  skin,  grew  to  the  size  of  a  hen's  egg,  broke,  and  was  discharging. 
The  reporters  conclude  that  there  were  three  members  in  one 
family  infected  with  blastomycetes. 

(Unfortunately,  the  nature  of  the  lesions  on  the  boy's  hip  was 
undetermined,  and  the  possibility  in  the  mother's  case  of  secondary 
infection  with  a  yeast  fungus  of  an  ordinary  open  and  discharging 
ulcer  cannot  be  eliminated.) 

Discussion 

DR.  JOSEPH  ZEISLER,  of  Chicago,  said  that  in  view  of  the  fact 
that  there  were  a  great  many  dermatologists  who  still  had  doubts 
as  to  the  genuineness  of  blastomycosis,  he  took  the  privilege  of 
briefly  discussing  this  subject,  as  he  had  seen  many  of  the  cases 
reported  by  Drs.  Hyde,  Montgomery,  and  Ormsby.  He  had  per- 
sonally had  one  case  of  systemic  blastomycosis  which  was 
extraordinary  in  many  ways.  One  feature  of  the  case  was  the 
development  of  abscesses  and  papillary  growths  of  the  skin,  and 
the  formation  of  an  enormous  abscess  in  the  gluteal  region  which 
discharged  about  half  a  pint  of  pus  daily.  The  patient  was  given 
potassium  iodide,  together  with  X-ray  and  other  methods  of  treat- 
ment, with  very  little  result.  She  finally  became  discouraged 
and  turned  to  Christian  Science.  Subsequently,  she  went  to 
California,  where  she  recovered  spontaneously. 

Dr.  Zeisler,  in  order  to  illustrate  the  difficulties  ofttimes  con- 
nected with  this  subject,  referred  to  the  case  of  a  young  woman, 
about  twenty,  who  fell  ill  with  a  high  fever  which  pointed  to  a 
pulmonary  infection  of  some  kind.  For  many  days  a  miliary 
tuberculosis  was  suspected.  She  was  seen  by  several  specialists, 
but  no  sputum  could  be  obtained  and  no  definite  diagnosis  was 
made.  Finally  sufficient  sputum  was  secured  and  submitted 
to  Dr.  Hektoen,  who  upon  microscopic  examination  found  the 
blastomycetes  present.  Dr.  Zeisler  said  this  case  emphasized 
the  fact  that  we  had  still  something  to  learn  in  regard  to  the 
possibilities  of  blastomycosis. 

DR.  T.  CASPAR  GILCHRIST,  of  Baltimore,  said  that  when  the  first 
specimens  of  blastomycosis  (described  at  that  time  as  protozoic 
dermatitis)  came  to  the  Johns  Hopkins  Hospital,  Dr.  Welch  was 


PLATE  XVIII— To  Illustrate  Dr.  Montgomery  and  Dr.  Ormsby's  Article. 


FIG.  1. — Photograph  showing  typical  cutaneous  lesion  with  metastatic 
lesions  below  (From  Case  3). 


* 


FIG.  2. — Photograph,  taken  five  weeks  before  death,  showing  nodules 
and  ulcers  on  limbs  (From  Case  5). 


PLATE  XIX— To  Illustrate  Dr.  Montgomery  and  Dr.  Ormsby's  Article. 


J^HI..M...    iJ*7:BnM 
FIG.  3. — Showing  group  of  giant  cells  containing  the  organisms  (X600). 


FIG.  4. — Sediment  from  tissue 
disintegrated  in  50  %  alcohol, 
showing  organisms  in  vari- 
ous stages  of  budding. 


FIG.  5.— Section  of  liver  showing  miliary 
abscesses  crowded  with  the  organ- 
isms (From  Case  5). 


PLATE  XX— To  Illustrate  Dr.  Montgomery  and  Dr.  Ormsby's  Article, 
a  b  c 


FIG.  6. — Cultures  four  weeks  old  :  (a)  on  glucose  agar ;  (b)  on  glycerine  agar 

grown  at  room  temperature ;  (c)  on  glucose  agar  grown 

in  incubator  (From  Case  14). 


FIG.  7. — Old  culture  showing  large  round  bodies  and  short  thick  mycelium 
containing  spore-like  bodies. 


DERMATOLOGICAL  CONGRESS  407 

in  doubt  whether  the  organisms  were  blastomycetes  or  protozoa, 
but  after  considerable  investigation  by  Dr.  Stiles,  it  was  decided 
that  the  case  was  one  of  protozoic  infection.  In  that  case,  the 
local  manifestations  were  present  for  ten  years  before  the  disease 
became  systemic. 

There  was  another  class  of  cases,  Dr.  Gilchrist  said,  in  which 
there  was  a  budding  formation  which  we  formerly  thought  char- 
acteristic of  the  blastomycetes.  Two  such  cases  had  been  reported 
in  negroes  in  which  the  skin  manifestations  were  accompanied 
by  large  subcutaneous  abscesses.  Upon  examination  of  the  blood, 
it  was  found  that  the  blood  of  these  patients  agglutinated  the 
organism.  Hektoen  had  made  similar  observations  and  Ophuls 
claimed  that  the  two  diseases  described  as  protozoic  dermatitis 
and  blastomycetic  dermatitis  were  alike.  Many  of  the  lesions 
in  these  cases  disappeared  spontaneously.  Whether  the  two 
organisms  belonged  to  the  same  group  the  speaker  said  he  did 
not  know.  Histologically  they  were  the  same. 

DR.  JAMES  NEVINS  HYDE,  of  Chicago,  said  he  believed  we  would 
eventually  settle  the  question  regarding  the  identity  or  non- 
identity  of  systemic  blastomycosis  and  granuloma  coccidioides. 
He  referred  to  one  point  to  which  he  thought  special  attention, 
thus  far,  had  not  been  paid  a  propos  of  the  case  referred  to  by 
Dr.  Zeisler,  in  which  the  speaker  said  he  had  made  the  original 
diagnosis.  He  had  noticed  that  in  sending  specimens  of  blastomy- 
cotic  disease  either  in  the  form  of  cultures  or  tissue  to  European 
colleagues,  they  had  reported  that  they  were  unable  to  make  a 
diagnosis  from  the  material  that  reached  them.  This  was  probably 
due  to  degeneration  of  the  organism  when  removed  from  its  more 
favorable  soil.  This  fact,  that  the  growth  seemed  to  be  limited 
in  possibilities  of  development  to  a  definite  region,  had  impressed 
him  more  deeply  in  every  succeeding  year  since  the  beginning  of 
these  observations;  and  in  a  communication  recently  published 
in  the  Journal  of  Cutaneous  Diseases  he  had  discussed  this  feature 
of  the  interesting  problem. 

In  the  first  case  mentioned  by  Dr.  Zeisler  the  patient  went  to 
California,  where  her  recovery  was  most  remarkable.  She  sub- 
sequently presented  herself  in  perfect  health,  showing  the  scars 
of  the  old  abscesses,  which  originally  had  been  opened  and  which 
contained  quantities  of  pus,  containing  pure  cultures  of  blas- 
tomycetes. 

Dr.  Hyde  said  the  fact  that  they  had  seen  so  many  cases  of 


4o8  SIXTH  INTERNATIONAL 

blastomycosis  in  Chicago  had  been  a  surprise  to  him  and  to  his 
colleagues  in  Chicago,  as  well  as  to  their  colleagues  in  New  York, 
Boston,  and  elsewhere.  He  felt  justified  in  saying  that  when 
studying  the  few  cases  reported  as  occurring  in  the  East,  the  symp- 
toms were  not  nearly  so  exaggerated  or  classical  as  those  observed 
in  Chicago.  He  therefore  had  the  conviction  that  the  organism 
which  produced  the  disease  was  more  or  less  restricted  to  a  fixed 
geographical  distribution  and  that  for  reasons  not  known  that 
special  area  of  favorable  soil  was  not  very  far  distant  from  Illinois 
and  Indiana.  It  was  there  that  the  organism  seemed  to  flourish 
as  it  did  nowhere  else. 

DR.  HOWARD  MORROW,  of  San  Francisco,  said  he  had  had  repeated 
opportunity  to  compare  cultures  of  blastomycetes  with  those  of 
the  granuloma  coccidioides,  and  he  had  found  that  they  varied 
considerably.  Both  cultures,  at  the  room  temperature,  had 
quite  a  characteristic  growth,  but  the  coccidioides  grew  in  the 
shape  of  a  thick  mass,  with  a  sharp  edge,  whereas  the  blastomy- 
cotic  fungus,  while  it  began  similar  to  that  of  the  coccidioides, 
after  a  few  days  developed  radiating  fibres  which  spread  out  and 
gave  the  appearance  of  a  halo.  The  speaker  exhibited  some  culture 
tubes  which  illustrated  the  difference  in  appearance  between  the 
two  fungi.  Of  course,  he  said,  they  were  closely  associated,  but 
this  was  simply  one  point  of  difference.  In  two  of  the  cultures 
of  blastomycetes  shown,  the  fungus  had  been  sent  to  him  by 
Drs.  Montgomery  and  Ormsby,  of  Chicago.  The  others  were 
taken  from  a  recent  unpublished  case  of  granuloma  coccidioides. 

DR.  DOUGLASS  W.  MONTGOMERY,  of  San  Francisco,  said  there 
is  no  doubt  that  there  is  a  marked  difference  between  the  two 
fungi  under  discussion.  It  is  held  by  zoologists  that  a  genetic 
difference  constitutes  a  marked  difference.  Genetically  there  is 
a  marked  difference  between  the  fungi  in  these  diseases.  In  the 
Illinois  disease  the  micro-organism  buds  in  the  tissues.  In  der- 
matitis coccidioides,  the  Calif ornian  disease,  the  organism  in  the 
tissues  is  a  capsule,  with  spores  in  it,  and  looks  like  canister-shot. 
The  organisms  are  beautifully  rounded  and  marked,  with  no  evi- 
dences at  all  of  budding,  and  with  a  life  cycle  in  the  tissues  of  their 
host,  which  is  entirely  different  from  what  it  is  outside  the  body. 
Dr.  Howard  Morrow  has  grown  both  of  these  organisms  (the  Cali- 
f ornian  and  the  Illinois  fungi)  on  the  very  same  media,  and  under 
the  same  conditions,  and  even  the  fungi  in  the  test  tubes  can  be 
distinguished  from  one  another,  as  the  one  shows  a  halo,  and  the 


DERMATOLOGICAL  CONGRESS  409 

other  forms  a  clump  of  fungus  without  any  halo  whatever.  He 
has  had  no  trouble  in  cultivating  the  Illinois  micro-organism  in 
California. 

DR.  OLIVER  S.  ORMSBY,  of  Chicago,  said  he  simply  wished  to 
emphasize  one  or  two  points  which  it  was  impossible  to  include 
in  the  synopsis  of  the  paper. 

In  reference  to  the  patient  referred  to  by  Dr.  Zeisler,  who 
recovered  in  California,  Dr.  Ormsby  said  the  case  appeared  to  be 
one  of  generalized  infection,  similar  to  pyaemia,  in  which  the 
deeper  organs  were  not  involved  to  any  extent.  That  patient 
had  received  large  doses  of  potassium  iodide,  which  unquestionably 
had  something  to  do  with  her  recovery,  in  addition  to  the  Christian 
Science  and  the  change  of  climate. 

Dr.  Ormsby  said  that  in  some  of  the  cases  described  in  this 
review  the  infection  was  limited  to  the  skin  for  some  time  but 
subsequently  became  generalized.  In  other  cases  the  generalized 
infection  occurred  first,  with  the  cutaneous  manifestations  months 
later.  He  was  sure  that  the  infection  was  carried  by  way  of  the 
blood,  although  evidences  of  that  were  not  obtainable  in  all  cases. 
The  bone  lesions  in  one  of  these  cases  were  of  two  types:  In  one 
type  there  were  erosions  about  the  bone,  while  in  the  other  there 
was  a  typical  osteomyelitis  of  blastomycotic  origin.  The  de- 
structive effects  of  this  organism,  and  its  ability  to  cause  death 
in  a  short  time  were  remarkable.  Four  cases  had  been  treated 
at  the  Cook  County  Hospital  within  a  brief  period.  One,  which 
began  as  a  pneumonia,  was  rapidly  fatal.  Blastomycosis  was 
really  a  very  serious  disease,  and  one  that  did  not  belong  entirely 
to  the  dermatologist.  It  was  important,  he  thought,  that  this 
fact  should  be  emphasized.  In  the  cases  they  had  seen  in  Chicago 
the  skin  had  been  involved  in  practically  all  but  one  instance. 


THE  THYROID  AS  A  FACTOR  IN  URTICARIA 

CHRONICA 

BY  DR.  M.  L.  RAVITCH,  OF  LOUISVILLE 

This  ten-minute  article  is  a  mere  therapeutical  suggestion 
of  experience  from  observation  of  nine  cases  of  persistent 
and  rebellious  chronic  urticaria.  We  know  well  that  as  in- 
significant as  is  an  attack  of  acute  urticaria,  so  serious  and 
obstinate  to  treatment  is  an  attack  of  obscure  and  chronic 
urticaria  that  it  may  prove  a  very  formidable  affection  and  may 
torment  the  life  out  of  a  patient.  In  regard  to  its  diagnosis, 
pathology,  and  treatment,  it  would  be  superfluous  to  annoy 
you  with  a  recital  of  what  is  known.  I  only  intend  to  discuss 
a  more  rational  and  not  simply  an  empirical  treatment.  I 
do  not  pose  as  an  authority.  I  merely  want  to  state  that  by 
careful  exclusion  of  all  probable  causes  of  chronic  urticaria, 
we  may  narrow  down  to  the  real  cause  and,  then,  we  may  put 
chronic  urticaria  in  the  category  of  curable  diseases.  I  may 
be  contradicted  by  competent  authorities,  but  then,  even 
competent  authorities  may  be  wrong.  I  firmly  believe  thyroid 
extract  to  be  a  specific  in  a  good  many  cases  of  chronic 
urticaria.  Thyrotherapy  had  the  same  experience  as  the 
X-ray  has  now.  When  it  was  first  brought  to  the  notice 
of  the  profession,  its  therapeutical  value  was  over-estimated. 
In  dermatology,  it  was  going  to  revolutionize  the  old  regime. 
False  and  extraordinary  claims  were  made  as  to  its  specificity 
in  psoriasis,  eczema,  lupus,  and  other  dermatoses.  As  loudly 
as  it  was  praised  at  the  beginning,  so  strongly  it  was  denounced 
and  abandoned  afterwards.  But  conservative  investigators 
were  not  discouraged  by  the  events.  Thyrotherapy  was 
proven  to  be  a  very  valuable  therapeutical  agent.  In  derma- 
tology, Dr.  Byrom  Bramwell,  Paschki,  and  Grosz  strongly 
recommended  it  in  psoriasis,  ichthyosis,  and  lupus  vulgaris. 

410 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS         411 

As  with  a  good  many  valuable  therapeutical  agents,  it  has 
its  indications  and  limitations,  though  it  was  argued  by  some 
that  in  certain  diseases,  like  eczema,  it  has  a  special  effect, 
because  it  improved  in  general  the  circulation  and  not  because 
of  its  specification;  yet  I  am  of  the  opinion  that  it  has  a  far 
wider  and  deeper  action.  According  to  the  opinion  of  a  con- 
siderable number  of  pathologists,  in  some  way  not  very  well 
understood  at  present,  the  thyroid  gland  has  the  power  of 
neutralizing  poisons  and  products  of  auto-intoxication  existing 
in  the  blood.  In  the  Hygienic  Laboratory  in  Washington, 
Dr.  Reid  Hunt  has  proven  that  very  small  amounts  of  thyroid 
will  protect  mice  against  poisoning  by  acetonitril;  this  I 
believe  is  the  first  definite  instance  in  which  any  antitoxic 
action  on  the  part  of  the  thyroid  has  been  definitely  proven 
by  experiment. 

Leopold-Levi  and  de  Rothschild  (see  Compt.  Rend.  Soc. 
de  Biol.,  Nov.,  1906)  also  came  to  the  conclusion  that  urticaria 
is  not  an  uncommon  expression  of  hypothyroidism,  and  that 
the  cutaneous  lesions  are  due  to  an  acute  intoxication.  They 
cite  certain  cases  of  urticaria  in  women  where  thyrotherapy 
caused  rapid  improvement  and  cure.  Mysterious  as  the 
thyroid  gland  is,  so  mysterious  is  its  effect.  One  fact  is  es- 
tablished in  my  mind;  as  thyroid  is  useful  in  eczema  of  the 
aged  where  the  gland  has  stopped  secreting,  so  it  is  useful 
in  obstinate  cases  of  urticaria  where  the  gland  is  more  or 
less  affected  or  functionally  inactive.  The  connection  between 
the  thyroid  gland  and  processes  in  the  uterus  has  long  been 
known.  A  good  many  disorders,  particularly  nervousness, 
have  been  justly  attributed  to  its  hypertrophy  or  atrophy. 
Abnormality  of  the  thyroid  in  hysterical  people  is  something 
more  than  an  accidental  accompaniment  and  that  chronic 
urticaria  is  an  auto-toxemia  caused  in  some  way  by  the  ab- 
normal condition  of  the  thyroid  is  certain.  Reasoning  from 
the  analogy  that  the  thyroid  is  a  much  more  active  and 
necessary  gland  in  women  than  in  men  and  knowing  that 
rebellious  cases  of  urticaria  are  also  found  more  in  women 
than  in  men,  my  conclusion  was  that  in  the  majority  of  cases, 
chronic  urticaria  was  due  to  the  disorders  of  the  thyroid.  In 
my  own  cases  of  chronic  urticaria  and  cases  seen  with  other 


4i2  SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

physicians,  from  two  to  four  weeks'  treatment  addressed  to 
neutralizing  the  toxins  elaborated  by  the  diseased  thyroid 
gland  produced  at  once  remarkable  improvement,  and  later 
on,  cures.  I  want  to  emphasize  that  in  atrophy  or  functional 
inactivity  but  not  in  very  enlarged  thyroid  glands,  desiccated 
thyroids  in  combination  with  nux  vomica  have  been  used, 
while  in  enlarged  glands  such  remedies  are  to  be  given  as  will 
allay  stimulation  or  diminish  the  secretion  of  the  thyroid, 
such  as  thyroidectin  (the  blood  of  thyrodectomized  animals) , 
strophanthus,  bromides,  and  atropin  and  X-ray. 

You  will  notice  that  the  last  four  remedies  have  been 
successfully  used  in  chronic  urticaria,  and  I  attribute  their 
success  to  their  influence  in  checking  or  diminishing  the 
abnormal  secretion  of  the  thyroid  gland. 

The  Roentgen  therapy  seems  to  do  better  than  drug 
medication.  In  my  own  experience  and  the  experience  of  the 
well-known  X-ray  worker,  Dr.  Freund,  and  also  others,  the 
Roentgen  treatment  induced  unmistakable  benefit  in  all 
cases  suffering  from  abnormal  functions  of  the  thyroid  and 
urticaria  due  to  oversecretion  of  the  thyroid.  Under  the 
X-ray  the  thyroid  was  reduced  in  size,  the  nervous  symptoms 
subsided,  and  weight  was  increased  in  almost  every  case. 
Improvement  in  some  cases  manifested  itself  in  two  weeks, 
and  in  two  months  the  patients  felt  well  enough  to  quit 
treatment. 

As  time  does  not  permit  me  to  describe  my  cases,  I 
will  only  state  that  seven  of  my  nine  cases  were  women. 
I  have  also  noticed,  as  is  the  case  with  patients  with  func- 
tional disorders  of  the  thyroid,  that  my  patients  complained 
that  they  were  out  of  order;  that  they  experienced  a  certain 
indescribable  feeling.  I  have  also  noticed  that  attacks  of 
urticaria  come  on  with  the  greatest  irregularity  and  without 
appreciable  cause.  There  being  no  assignable  causes  in  most 
of  the  cases  of  obstinate  urticaria  to  account  for  these  attacks, 
one  cannot  help  but  think  they  must  be  purely  toxic  and 
that  functional  disorders  of  the  thyroid  were  the  cause  of  this 
toxic  condition. 


HYDROA  PUERORUM  (UNNA) 

By  DR.  MARCUS  HAASE,  OF  MEMPHIS,  AND  DR.  ROSE  HIRSCHLER, 

OF  PHILADELPHIA 

IT  seems  fateful  that  eighteen  years  after  Unna A  so  nobly 
defended  the  teachings  of  Bazin,  your  authors  should  find 
it  necessary  to  appear  before  this  international  body  and  ask 
for  the  proper  recognition  of  a  work  which  so  clearly  defined 
the  disease  under  consideration  that  it  seems  almost  incom- 
prehensible that  the  English  and  American  authorities  should 
have  classed  it  as  they  have — under  that  horribly  disfiguring 
dermatosis,  hydroa  vacciniforme. 

Crocker,2  under  the  general  head  of  hydroas,  speaking  of 
dermatitis  herpetiformis,  says:  "Unna's  hydroa  puerorum  is 
a  sub-variety,"  but  under  the  title  of  hydroa  vacciniforme 
seu  aestivale  uses  it  as  a  synonym  of  this  disease,  although  in 
the  text  he  does  say  that  "  it  must  be  admitted  that  Unna's 
cases  differ  somewhat  from  the  others  in  several  respects,  one 
important  difference  being  that  the  vesicles  and  bullae  were 
quite  superficial  and  left  no  scars  and  often  the  lesion  stopped 
short  at  an  early  stage  or  remained  as  papules. " 

Jackson3  classes  hydroa  puerorum  under  hydroa  vaccini- 
forme, and  says:  "  It  occurs  mostly  in  boys  and  on  exposed 
parts.  .  .  .  Vesicles  are  prone  to  become  depressed  in  the 
centre  and  resemble  vaccine  vesicles.  Scarring  apt  to  result. 
.  .  .  Clinical  relation  to  bullous  erythema  and  herpetiform 
dermatitis,  though  differing  from  them  in  leaving  scars." 

Pusey4  uses  the  term  hydroa  puerorum  as  a  synonym  for 
hydroa  vacciniforme  without  any  qualification,  and  in  a 
footnote  says:  "Hydroa  was  a  name  formerly  given  to  many 
bullous  eruptions ;  the  only  disease  in  which  the  name  survives 
is  hydroa  vacciniforme." 

Stelwagon5  also  uses  the  name  as  a  synonym  for  hydroa 
vacciniforme,  but  in  the  footnote  on  literature  quotes  Unna's 
cases  in  the  Monatshefte  as  questionable  ones. 

413 


4i4  SIXTH  INTERNATIONAL 

Hyde  and  Montgomery,6  under  the  title  of  hydroa  vaccini- 
forme,  use  hydroa  puerorum  as  a  synonym,  but  in  the  text, 
classing  it  with  hydroa  sestivale  and  summer  prurigo,  say: 
"  The  eruptions  differ  from  those  of  hydroa  vacciniforme 
chiefly  in  being  acuminate  papules  of  a  light  reddish  hue 
with  minute  vesicles,  which  are  not  umbilicated,  and  scarring 
is  comparatively  slight.  The  disease  is  found  in  girls,  though 
less  frequently  than  in  boys." 

All  this  after  the  title  of  Unna's  paper  was:  "Concerning 
Duhring's  Disease  and  a  New  Form  of  the  Same. " 

Was  ah1  this  confounding  of  two  diseases  due  to  his  de- 
scription of  one  case  in  which  the  majority  of  lesions  appeared 
on  the  face,  ears,  and  neck,  or  was  his  defence  of  Bazin's  classi- 
fication taken  as  a  report  of  cases  of  that  disease  (hydroa 
vacciniforme)  which  he,  Bazin,  was  the  first  to  so  clearly 
define? 

The  case  reported  below  was  seen  by  one  of  us  with  Dr. 
Unna  in  his  private  clinic  in  Hamburg  in  October,  1906.  He 
said  it  was  a  typical  case  of  what  he  meant  by  the  term  hydroa 
puerorum. 

The  previous  history  given  was  furnished  by  the  mother  of 
the  child,  a  woman  of  much  more  than  ordinary  intelligence: 

S.  E.  M.,  age  eight,  male,  white,  of  English  birth. 

Family  history  unimportant.  There  is  one  other  child 
in  the  family,  a  girl,  who  is  unaffected. 

Previous  history :  Had  pertussis  at  seven  months ;  rubella 
at  three  years;  varicella  at  five  years.  No  other  contagious 
diseases.  General  physical  condition  good. 

History  of  previous  attacks:  First  attack  began  in  infancy, 
spots  occurring  at  different  times,  attributed  by  the  mother 
to  teething. 

In  the  summers  of  the  second  and  third  years,  he  had 
several  very  severe  attacks,  blisters  varying  in  size  from  a 
pinhead  to  a  threepenny-piece,  on  all  parts  of  the  body 
except  his  head. 

This  occurred  three  or  four  times  in  the  summer,  one 
efflorescence  succeeding  another  before  the  preceding  one 
had  completely  disappeared,  but  these  efflorescences  were  less 
severe  than  the  original  outbreak. 


DERMATOLOGICAL  CONGRESS  415 

There  would  then  be  a  period  of  quiescence  lasting  from 
two  weeks  to  four  months,  when  the  lesions  would  again 
appear. 

During  the  winter  of  his  second  year  he  had  two  mild  but 
distinct  attacks,  and  each  winter  since  the  same  condition 
has  been  noted. 

The  eruption  was  less  severe  during  his  fourth  and  fifth 
years,  but  in  both  these  years  it  appeared  twice  on  the  face, 
three  or  four  spots  occurring  in  that  region,  but  healing  much 
more  quickly  than  those  on  the  trunk  and  limbs. 

Each  year  since  he  has  had  attacks,  but  none  so  severe 
as  those  that  occurred  during  his  second  and  third  summers. 

In  August  of  this  year,  he  had  rather  a  severe  attack,  the 
lesions  appearing  first  on  the  back  and  chest,  then  on  the  legs, 
arms,  hands,  and  feet  in  the  order  named.  Later  three  lesions 
appeared  on  the  face,  but  these  disappeared  in  three  or  four 
days. 

On  two  occasions,  mild  acute  attacks  followed  visits  to  the 
dentist. 

The  child  is  unusually  quiet,  not  inclined  to  play  just 
previous  to  or  during  the  attack. 

Present  history,  October  16,  1906: 

Patient,  a  blond,  appeared  to  be  a  fairly  well  developed 
child,  fond  of  outdoor  life,  but  of  a  nervous  temperament;  no 
lung  or  cardiac  disease. 

Upon  examination,  no  scarring  was  found  except  one  small 
pit  upon  the  forehead,  which  the  mother  insisted  was  the  re- 
mains of  an  infected  varicella  vesicle. 

Present  attack  began  on  the  loth  inst.,  with  one  small 
lesion  on  the  right  cheek,  which  when  seen  was  covered  with  a 
pale  yellow  slightly  adherent  crust.  On  the  i2th,  four  lesions 
appeared  on  the  back,  quickly  followed  by  others,  and  at  pres- 
ent they  are  now  sparsely  disseminated  over  the  trunk  and 
extremities,  some  thirty  lesions  in  all.  No  others  appeared 
on  the  face,  nor  are  there  any  on  the  ears  or  hands.  The  lesions 
began  as  erythematous  patches,  irregular  in  outline,  varying 
in  size  from  a  pinhead  to  a  thumb-nail,  accompanied  by 
intense  itching  and  burning.  Within  twelve  to  fifteen  hours, 
minute  tense  vesicles  appeared  upon  these  erythematous 


416  SIXTH  INTERNATIONAL 

bases.  These  vesicles  were  decidedly  superficial,  easily  rup- 
tured through  scratching,  which  relieved  to  a  considerable 
degree  the  subjective  symptoms.  In  the  majority  of  in- 
stances, they  coalesced  and  formed  bullae.  They  contained 
clear  to  a  straw-colored  serum,  were  not  pustular,  except 
when  extraneously  infected.  Yellowish  crusting  followed.  No 
ulceration.  In  a  few  days,  crusts  fell  off  and  left  red  stains 
with  no  scarring.  We  saw  no  erythematous  patches  that 
remained  as  such.  Biopsy  made  from  lesion  over  left  tendon 
Achilles. 

October  i  yth,  one  new  lesion  on  dorsum  of  fourth  toe,  right 
foot. 

The  crust  on  right  cheek  had  fallen  off,  leaving  a  deep  red 
stain.  There  was  no  pitting.  Urinary  analysis  made — ap- 
pended. October  i8th,  no  new  legions  appeared.  An  unsatis- 
factory blood  examination  was  made  October  i  yth.  A  second 
one  done  on  October  2oth.  Both  appended.  When  seen  on 
October  2oth,  crusts  from  three  of  the  first  lesions  occurring 
on  the  back  had  fallen  off,  leaving  stains  similar  to  that  on 
the  cheek.  There  was  no  scarring  in  any  of  these. 

Crusting  continued  up  to  time  patient  was  last  seen. 

The  disease  has  only  recurred  twice  since  this  attack.  A 
moderately  severe  attack  occurred  in  February,  beginning 
on  the  eighth,  lesions  appearing  first  on  the  buttocks,  quickly 
followed  by  a  similar  condition  on  the  back,  abdomen,  and  legs, 
in  all  about  twenty-five  bullae. 

An  insignificant  attack  occurred  on  the  23d  of  July,  con- 
fined to  the  extremities  and  limited  to  eight  lesions,  three  on 
the  outer  side  of  right  calf,  two  on  left  leg,  and  three  on  right 
forearm. 

In  neither  of  these  attacks  did  any  lesions  appear  on  the 
face,  ears,  hands,  or  feet.  The  first  attack  this  year  lasted 
about  eight  days,  the  second  one  in  July  crusting  and  falling 
off  in  five  days. 

Histopathology : 

Upon  studying  the  sections  made  from  the  biopsy  one  is 
forced  to  the  conclusion  that  the  disease  is  an  acute  inflamma- 
tory affection,  with  destruction  of  its  component  elements 
rather  than  proliferative  growth.  Vesiculation  is  the  ultimate 


DERMATOLOGICAL  CONGRESS  417 

outcome  of  the  process.  The  factors  productive  of  the  vesicu- 
lation  must  be  of  a  less  violent  action  than  some  of  our  vesicular 
diseases,  as  in  no  instance  is  there  visible  a  sudden,  sharp 
uplifting  of  the  epidermis  in  toto,  forming  a  solid,  overhanging 
roof. 

The  serous  exudation  into  the  epidermis  must  be  a  slow 
process.  There  is  seen  through  the  prickle  layer  an  intense 
intercellular  oedema,  the  intensity  varying  irregularly  through- 
out the  whole  depth  of  the  rete,  being  of  course  greatest  through 
the  central  area  of  the  biopsy.  The  oedema  is  such  that  it 
stretches  the  protoplasmic  processes  to  their  utmost,  fre- 
quently compressing  the  exoplasm,  thus  reducing  the  size  of  the 
cell.  This  is  observed  in  the  upper  part  of  the  rete.  Again 
the  compression  has  proceeded  farther,  so  that  in  some  areas 
the  cell  wall  has  given  way,  freeing  the  nuclei  into  scattered 
groups,  allowing  them  to  float  in  small  spaces,  which  form 
the  early  start  for  small  vesicles.  This  type  is  found  in  greater 
numbers  in  the  upper  rete  layers. 

As  the  intercellular  fluid  increases  in  amount  and  the 
protoplasmic  bridges  give  way,  larger  vesicles  are  formed. 
The  nuclei  gradually  break  from  their  boundaries  and  float  as 
part  of  the  vesicular  contents.  Some  of  the  epidermal  cells 
resist  the  dissolving  power  of  the  serum,  but  are  not  able  to 
retain  their  shape.  They  become  pressed  into  long,  narrow 
cells,  some  spindle-shaped  with  elongated  or  crinkled  nuclei, 
and  hang  as  bands  downward  from  the  roof,  connect  some- 
times with  the  floor  below  or  hang  loose,  or  join  with  a  nearby 
streamer,  thus  forming  multilocular  cavities. 

The  nuclei  sometimes  have  their  shape  preserved.  They 
are  never  cedematously  swollen  and  are  never  ballooned.  They 
are  more  apt  to  be  crinkled  and  irregular. 

The  base  of  the  vesicles  may  have  a  narrow  or  a  broad 
zone  of  basement  cells  or  none  at  all.  The  lateral  walls  of  the 
large  vesicles  usually  have  their  cells  long  and  narrow.  In 
the  small  vesicles  the  cells  seem  to  have  melted  away,  leaving 
but  their  nuclei,  while  the  neighboring  processes  form  their 
boundaries.  The  roof  of  the  larger  vesicles  has  always  held 
firm,  unyielding  corneum  and  some  portion  of  the  granular 
layer,  two  rows  of  which  are  generally  present;  some  of  the 


4i  8  SIXTH  INTERNATIONAL 

smaller  ones  have  also  several  layers  of  undisturbed  rete. 
There  have  been  no  nucleated  corneus  cells  found.  There 
has  always  been  a  clean  sweep  through  the  whole  section  of 
normal  horny  cells. 

A  very  few  vesicles  have  been  found  between  the  granular 
and  horny  layers,  the  granular  layer  appearing  cloudy  from 
oedema,  taking  the  stain  poorly.  A  few  of  the  vesicles  appear 
to  be  in  the  act  of  crust  formation  with  exfoliation  without 
causing  much  downward  pressure. 

In  the  peripheral  regions  of  the  sections  beyond  the  vesicu- 
lar areas  the  prickle  cells  have  oedematous  swelling  without 
the  intense  intercellular  pressure.  Here  the  epithelial  plugs 
seem  rather  broad  and  full,  with  no  mitoses.  In  fact,  there 
is  no  mitosis  anywhere  to  be  seen  in  the  rete,  and  no  evidence 
of  any  newly  formed  cells.  The  contents  of  the  vesicles 
consist  of  granules  and  threads  of  fibrin.  Intermingled  in  the 
meshes  are  the  nuclei  and  an  occasional  isolated  undissolved 
epithelial  cell,  minus  its  nutrient  processes;  also  granular 
debris.  The  most  marked  feature  is  the  multitude  of  mono- 
and  multi-nuclear  leucocytes.  They  swarm  the  vesicles, 
especially  at  their  bases  and  in  the  very  small  amount  of 
corium  present. 

After  repeated  attempts  no  eosinophiles  can  be  found. 
Leucocytes  are  found  everywhere.  They  roll  and  wedge 
themselves  in  from  the  germinal  layer  up  through  the  granular 
stratum  almost  into  the  corneum.  Mast  cells  are  present 
throughout,  being  most  conspicuous  at  the  vesicular  floor. 

One  scarcely  would  believe  that  scarring  would  be  present, 
though  the  vesicles  sometimes  maintain  the  whole  depth  of 
the  epidermis. 

It  would  appear  that  there  would  be  sufficient  basal 
epithelial  cells  left  to  renew  the  broken  continuity,  preventing 
at  least  any  breadth  of  scar.  (Polychrome,  Methylene  Blue, 
Iron  Hematoxylin  and  Eosin,  Delafield's  Hematoxylin  and 
Eosin,  and  other  stains  used.) 

It  will  be  remembered  that  in  Bowen's7  cases  many 
vesicles  became  depressed  in  the  centre  and  resembled  vaccina- 
tion vesicles,  and  around  the  umbilicated  centre  there  was  often 
a  ring  of  fluid  and  a  dark  red  areola.  Dark  blue  or  black 


DERMATOLOGICAL  CONGRESS  419 

centres  due  to  the  necrotic  and  hemorrhagic  corium  were  seen 
through  the  overlying  vesicles.  Necrosed  centres  becoming 
converted  into  thick  black  crusts  were  detached  with  difficulty, 
leaving  deep  scars,  "permanent  variola-like."  In  sections 
from  one  of  the  biopsies  he  found  that  necrosis  extended  down 
throughout  the  entire  epidermis  and  through  the  corium, 
ceasing  a  short  distance  only  from  the  subcutaneous  tissue. 
A  second  biopsy  from  the  same  case  of  Bowen's,  consisting 
of  a  small  primary  vesicle  without  the  typical  central  dis- 
coloration, showed  a  vesicle  in  the  centre  of  the  rete  without 
the  necrosis,  as  in  the  first  biopsy.  But  this  was  not  char- 
acteristic of  the  lesions.  He  says  that  as  far  as  these  sections 
indicate,  "  the  disease  begins  as  an  inflammation  in  the  epi- 
dermis and  upper  part  of  the  corium  in  circumscribed  areas, 
and  speedily  results  in  the  formation  of  vesicles  in  the  rete. 
In  these  lesions  they  do  not  end  here,  the  epidermis  and  corium 
underlying,  deep  down,  become  necrotic,  all  of  which  show  and 
give  rise  to  the  dark  red  centre  seen  in  the  well-developed 
lesion,  and  to  the  dark  violet  points  as  described." 

In  McCall  Anderson's8  two  cases  of  hydroa  aestivale  the 
lesions  were  limited  to  the  face,  ears,  neck,  and  hands,  and 
the  vesicles  which  broke  with  crusting  left  severe  scarring, 
even  to  the  point  of  contractures.  Unfortunately  there  was 
no  biopsy  made  in  these  interesting  cases.  However,  here, 
as  in  Bowen's,  there  must  have  been  a  deep  necrosis,  much 
deeper  than  the  epidermis. 

In  J.  C.  White's9  article  on  hydroa  vacciniforme,  he 
claims  that  the  lesions  left  scars  and  pits  and  that  excoriations 
and  crusts  were  present  with  the  lesions ;  and  he  has  observed 
other  instances  of  children  where  the  lesions  were  confined  to 
the  ears  and  backs  of  hands,  characterized  by  umbilicated  and 
necrotic  conditions,  recurrence,  and  cicatrices,  and  that  these 
are  typical  of  Bazin's  disease,  hydroa  vacciniforme.  In  his 
article  he  quotes  Duhring  to  have  said:  "I  believe  scarring 
may  occur  in  dermatitis  herpetiformis,  but  it  is  rare,  especially 
in  a  marked  form,  and  I  regard  such  cases  as  peculiar — that  is, 
where  scars  exist  a  year  or  two  after  the  eruption  had  dis- 
appeared." White  here  also  says  that  "  Unna's  hydroa 
puerorum  is  certainly  a  different  affection." 


420  SIXTH  INTERNATIONAL 

Handford10  reports  a  case  of  hydroa  aestivale  in  which  the 
disease  was  limited  to  the  face  and  left  scars,  and  mentions  a 
case  of  Mr.  Hutchinson's,  described  at  a  meeting  of  the  Clinical 
Society  of  London,  December  14,  1888,  that  had  been  under 
Mr.  Hutchinson's  observation  from  the  years  eight  to  twenty, 
and  which,  while  disseminated  over  the  whole  body,  was 
sparse  on  the  trunk,  worse  on  the  hands  and  face,  and  es- 
pecially severe  on  the  ears,  and  "  his  face  was  scarred  all  over, 
as  if  from  smallpox,  and  the  ears  were  reduced  to  a  gristle 
covered  by  thin  scars."  The  patient  was  never  wholly  well 
excepting  in  cold  weather. 

Elliot11  believes  his  case  to  be  the  same  as  Tilbury  Fox's 
hydroa  simplex,  in  which  there  was  little  crusting  and  no 
scarring.  A  biopsy  of  a  freshly  occurring  lesion  was  made. 
In  this  section  work  the  stratum  corneum  was  broad  and  well 
defined,  with  loosened  and  separated  layers,  especially  near 
the  vesicles,  but  marked  around  "  that  portion  of  the  sweat 
ducts  which  passed  through  it,"  and  over  some  of  these  latter 
it  was  raised,  forming  vesicles.  The  nuclei  were  retained 
almost  to  the  surface.  The  stratum  lucidum  was  scarcely 
demonstrable,  and  the  stratum  granulosum  was  seen  limited 
to  a  single  layer. 

The  rete  near  the  vesicle  became  acanthotic,  more  than 
doubling  itself.  The  cells  became  long  and  narrow,  slightly 
granular  and  somewhat  loosened,  nuclei  occasionally  absent, 
but  as  a  whole  they  were  well  stained. 

He  speaks  of  its  being  an  inflammatory  reaction,  but  does 
not  speak  of  the  marked  stream  of  leucocytes  into  the  vesicles 
and  surrounding  areas. 

In  his  summary  he  concludes  "  that  the  point  of  origin  of 
these  lesions  is  primarily  in  the  epithelia  of  the  sweat  ducts 
just  below  the  horny  layers  of  the  epidermis,  extending  from 
there  to  the  rete ;  and  that  the  secondary  symptoms  are  those 
of  inflammation  seated  especially  in  the  papillary  layer." 

One  can  see  that  there  are  a  number  of  differences  between 
the  histology  of  this  case  and  that  of  ours. 

In  the  specimens  of  hydroa  puerorum  no  connection  was 
seen  between  the  coil  glands  and  the  vesicles. 

In  Gilchrist's12  report  of  a    case    of    dermatitis    herpeti- 


DERMATOLOGICAL  CONGRESS  421 

formis  of  Duhring,  he  says  that  it  is  apparent  that  the  vesicles 
are  formed  gradually  between  the  epidermis  and  the  corium. 
That  the  changes  have  chiefly  occurred  in  the  upper  part  of 
the  corium,  which  shows  an  invasion  of  the  acute  process. 
He  speaks  of  first  a  few  wandering  polynuclear  leucocytes 
in  the  epidermis,  but  "by  no  means  numerous."  In  one  or 
two  places,  especially  near  the  large  vesicles,  a  few  vesicular 
spaces  occurred  in  the  epidermis,  but  connected  with  the 
vesicle  below.  No  mitosis  was  present.  Some  of  the  nuclei 
were  shrunken  and  appeared  to  be  situated  in  a  vacuole. 
No  alterations  were  noticed  in  a  sweat  duct  appearing 
to  pierce  it.  On  account  of  the  pressure  from  the  vesicle  the 
cells  of  the  overhanging  epidermis  were  somewhat  flattened. 

Some  eosinophiles  were  found  in  the  vesicles.  The  corium 
was  most  markedly  affected.  Many  polynuclear  leucocytes 
were  found  here,  as  well  as  mononuclear  cells  and  undoubted 
eosinophiles.  These  eosinophiles  seemed  to  be  prominent, 
"even  under  low  power."  As  the  stages  grow  later,  the 
leucocytes  grow  in  numbers,  apparently  being  the  main 
changes,  but  no  corresponding  growth  of  eosinophiles.  Later 
still,  the  papillae  grow  larger,  obliterating  the  interpapillary 
spaces  and  increasing  the  size  of  the  vesicles,  with  a  corre- 
sponding increase  of  cells.  "The  greatest  variety  of  cells  is 
seen  at  the  base  of  the  vesicles. " 

In  a  brief  summary  there  is  noted  that  dilatation  oc- 
curs first  in  the  blood-vessels  in  the  upper  part  of  the  corium, 
particularly  the  papillae,  serum  exudation  as  evidenced  by 
coagulated  albumin,  with  emigration  of  polynuclear  leuco- 
cytes, eosinophiles,  and  fibrin  in  the  connective  tissue.  Then 
there  is  a  massing  of  polynuclear  leucocytes,  chiefly  in  the 
upper  part,  with  displacement  of  papillae.  As  this  increases, 
diapedesis  of  eosinophiles  is  more  noticeable.  This  continues 
until  sufficient  to  produce  vesiculation. 

Pitting  and  scars  occur  with  this  disease  because  the 
vesicle  is  entirely  beneath  the  epidermis,  which  is  simply 
raised  in  a  mechanical  manner  by  the  inflammatory  exuda- 
tion beneath.  The  epidermis  is  in  itself  normal,  although 
over  the  vesicle  it  appears  flattened  out.  The  process  is 
an  acute  one,  as  seen  by  the  polynuclear  leucocytes.  The 


422  SIXTH  INTERNATIONAL 

changes  do  not  extend  very  deep  into  the  corium.  The 
glands  are  unaffected. 

Gilchrist  says  that  here  the  picture  does  not  entirely  agree 
with  Unna's,  although  the  changes  have  occurred  in  the  corium 
in  the  papillary  bodies,  and  the  vesicles  were  formed  beneath 
the  epidermis.  In  this  case  he  (Gilchrist)  believes  that  the 
process  was  more  acute. 

Others  have  agreed  in  the  report  of  the  diapedesis  .of 
eosinophiles.  It  is  certain  that  there  are  none  present  in  the 
specimens  we  have  of  hydroa  puerorum.  It  may  be  that  the 
process,  though  acute,  was,  as  has  been  said  before,  not  so  acute 
as  to  create  the  outpouring  of  eosinophiles,  but  sufficient  to 
produce  the  outpouring  of  polynuclear  leucocytes. 

The  findings  of  Gilchrist  correspond  more  with  our  findings 
than  the  other  men's  in  their  hydroa  vacciniforme. 

The  sudden  stream  of  leucocytes  and  serum  into  the 
epidermal  tissue  would  account  for  the  preliminary  erythema 
and  swelling.  It  can  be  seen  that  deeply  seated  small  vesicles 
may  exist  under  a  firm,  horny  roof,  and  still  present  grossly 
the  appearance  of  papular  lesions.  The  multiplicity  of  the 
vesicles  may  also  be  evidenced  as  true  vesicles  in  groups,  or 
grossly  as  isolated  vesicles,  while  isolated  there  are  microscop- 
ically more  present. 

Brooke,13  who  reports  two  typical  cases  (one  in  a  girl)  of 
hydroa  vacciniforme,  quotes  from  the  report  of  Buri's14  case, 
who  in  turn  quotes  Bazin's15  original  article  describing  the 
disease,  as  follows: 

"Hydroa  vacciniforme  is  a  rare  and  little  known  affection. 
The  majority  of  cases  were  taken  for  syphilis  and  scrofula. 
They  were  of  long  duration  and  resisted  the  most  varied 
methods  of  treatments.  Symptoms  .  .  .  appear  first  after  an 
exposure  to  fresh  air  or  to  the  rays  of  a  powerful  sun.  Some 
feeling  of  malaise  and  loss  of  appetite  often  accompany  the 
outbreak.  The  eruption  often  shows  itself  primarily  upon 
the  unclothed  parts  of  the  body,  especially  the  nose,  the  cheeks, 
the  hands,  and  later  upon  the  other  parts.  Red  patches  are 
first  noticed,  on  which  transparent  vesicles  of  herpes  appear. 
From  the  second  day  the  vesicles  present  a  distinct  dell; 
they  soon  lose  their  transparency,  and  at  this  moment  they 


DERMATOLOGICAL  CONGRESS  423 

resemble  a  variola  or  vaccine  pustule;  in  a  short  time  a  crust 
forms  extending  from  the  centre  towards  the  periphery.  In 
some  patients  the  numerous  scars  give  a  distinct  impression  of 
a  previous  variola,  in  others  the  sero-purulent  secretion  and 
the  thick  crust  would  lead  one  to  the  belief  that  the  case  was 
one  of  impetigo,  did  not  a  few  outlying  efflorescences  in  the 
course  of  development  prevent  such  an  error.  The  affection 
often  drags  on  for  months,  owing  to  the  development  of 
constant  fresh  eruptions.  In  one  case  it  lasted  six  months 
continuously.  Relapses  are  frequently  seen,  originating 
from  the  changes  in  the  temperature." 

After  the  foregoing,  we  do  not  think  there  can  remain 
any  reasonable  doubt  that  these  are  separate  and  distinct 
diseases. 

Clinically  there  are  but  two  similar  features :  first,  that  the 
lesions  are  grouped  vesicular  ones;  second,  they  both  occur 
in  young  males.  There  the  similarity  ends. 

In  hydroa  vacciniforme  the  disease  occurs  almost  ex- 
clusively on  the  face,  ears,  and  hands.  The  grouped  veiscles 
coalesce,  form  bullae,  become  umbilicated  with  dark  blue  or 
black  centres.  The  crusts  are  thick  and  black  and  are  very- 
adherent,  and  upon  removal  leave  distinct  ulcers,  and  the 
ultimate  outcome  of  the  process  is  variola-like  pitting  and 
scarring. 

In  our  case  of  hydroa  puerorum,  the  face  was  the  region 
least  affected,  the  trunk  and  limbs  being  the  most  seriously 
involved. 

The  grouped  vesicles  or  bullae  were  never  dark,  being  from 
a  clear  to  straw  color.  There  was  no  umbilication.  The 
crusts  were  light  yellow  and  slightly  adherent,  and  when  re- 
moved left  only  deep  red  stains.  There  was  never  any  pitting. 
All  of  this  is  true  of  the  five  cases  reported  by  Unna,  except 
one  in  which  the  majority  of  lesions  appeared  on  the  face. 

In  hydroa  vacciniforme  the  heat  of  the  sun,  and  to  a  less 
degree  cold  winds,  are  the  exciting  causes.  This  is  not  neces- 
sarily true  in  hydroa  puerorum,  as  evidenced  by  the  two 
attacks  following  visits  to  the  dentist,  and  the  attack  which 
we  were  fortunate  enough  to  witness,  which  began  on  October 
loth,  in  exceedingly  mild  and  pleasant  autumn  weather. 


424  SIXTH  INTERNATIONAL 

As  to  the  histology  of  the  two  diseases,  there  is  even  a  more 
marked  difference  than  in  the  clinical  pictures,  as  is  shown  by 
comparing  the  findings  of  those  quoted  with  our  own. 

In  Unna's  article  he  describes  hydroa  puerorum  as  a  form 
of  Duhring's  disease.  Can  this  position  be  sustained  to-day? 
We  do  not  think  so. 

Few  cases  of  Duhring's  disease  have  been  reported  as 
occurring  in  children,  none  beginning  in  the  first  year.  The 
youngest  on  record  we  believe  to  be  three  years  of  age,  reported 
by  Crocker. 

Hydroa  puerorum  begins  in  the  first  year.  In  Duhring's 
disease,  the  lesions  are  polymorphous.  In  hydroa  puerorum, 
the  polymorphism  is  decidedly  limited. 

The  duration  of  Duhring's  disease  is  from  three  weeks  to  as 
many  months.  Hydroa  puerorum  is  a  disease  of  short  du- 
ration, attacks  rarely  lasting  over  fifteen  days. 

In  Duhring's  disease,  male  and  female  are  alike  susceptible. 
In  hydroa  puerorum,  only  the  male  is  attacked. 

The  difference  histologically  is  much  more  marked,  as  is 
shown  in  Gilchrist's  masterly  description  of  his  findings,  and 
Unna16  summarizes  the  histological  condition  as  follows: 

"The  oedema  and  cellular  infiltrations  corresponding  to  a 
vesicular  area  of  the  skin  whose  chief  seat  is  in  the  papillary 
body,  the  utterly  passive  behavior  of  the  epithelium  which 
only  presents  oedema  and  interepithelial  blisters  or  is  com- 
pletely elevated  by  serum,  and  finally  the  complete  absence 
of  leucocytes." 

In  claiming  for  this  disease  a  place  in  our  nomenclature  as 
a  dermatological  entity,  we  offer  the  following  description 
culled  largely  from  the  original: 

First,  an  acute  erythemato-vesicular  disease,  preceded 
and  accompanied  by  intense  burning  and  itching. 

Second,  the  vesicles  coalescing  to  form  bullas. 

Third,  involution  of  lesions  without  pitting  and  scarring. 

Fourth,  the  first  attack  occurring  in  the  first  year  of  life. 

Fifth,  recurrence  of  attacks  independent  of  external 
influences. 

Sixth,  gradual  lessening  of  attacks  in  extent,  intensity, 
and  duration. 


DERMATOLOGICAL  CONGRESS  425 

Seventh,  spontaneous  disappearance  at  puberty. 

Eighth,  unrestricted  as  to  any  particular  region. 

Ninth,  restricted  to  male  sex. 

Tenth,  relatively  normal  health  during  attacks. 

Eleventh,  to  this  may  be  added  the  superficial  character 
of  the  disease,  the  lesions  being  confined  to  the  rete. 

We  acknowledge  with  thanks  our  indebtedness  to  Dr. 
Unna  for  allowing  us  to  study  the  case,  and  to  Dr.  Carl  Enoch, 
of  Hamburg,  for  urinalysis  and  blood  examinations. 

URINALYSIS 

Reaction Acid 

Specific  gravity 1.027 

Total  solids 6.29  % 

Albumin none 

Sugar none 

Acetone none 

Bile  pigment none 

Chlorides 76  % 

Phosphates 243  % 

Uric  acid  and  urates 033  % 

Urea 1.38  % 

Residue — sulphates,  etc. 

BLOOD  EXAMINATION 

October  17,  1906: 

The  counting  of  the  red  blood  corpuscles  showed  the 
normal  number  of  4,800,000. 

The  proportion  of  the  red  to  the  white  blood  corpuscles 
could  not  be  ascertained,  as  in  five  preparations  not  one 
leucocyte  was  found  on  the  counting  chamber.  Only  in  the 
sixth  preparation  one  leucocyte  was  found  outside  the  chamber. 

The  stained  preparations  did  not  show  any  difference  from 
the  normal,  aside  from  the  fact  that  we  found  that  here  also 
the  number  of  leucocytes  appeared  diminished. 

However,  as  the  above  finding  may  have  possibly  been 
accidental,  I  would  recommend  a  second  counting. 


426        SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

October  20: 

Haemoglobin 67% 

Red  corpuscles 4,596,000 

White  corpuscles 8,000 

There  was  no  increase,  rather  a  diminution  of  eosinophiles. 

(Signed)  Dr.  CARL  ENOCH. 

REFERENCES 

1.  UNNA.     Monatshefte  /.,  prdk.  Derm.  August,  1889. 

2.  CROCKER.     Diseases  of  the  Skin.     Third  edition. 

3.  JACKSON.     Diseases  of  the  Skin,  1901. 

4.  PUSEY.     Principles  and  Practice  of  Dermatology,   1907. 

5.  STELWAGON.     Diseases  of  the  Skin.     Fourth  edition. 

6.  HYDE  and  MONTGOMERY.     Diseases  of  the  Skin.     Seventh  edition. 

7.  BOWEN.     Journal  of  Cutaneous  and  Genito-Urinary  Diseases,  March, 

1894. 

8.  McCALL    ANDERSON.     British   Journal   of   Dermatology,     January, 

1898. 

9.  J.  C.  WHITE.     Journal  of  Cutaneous  and  Genito-Urinary  Diseases, 

1898,  p.  514. 

10.  HANDFORD.     Illustrated  Medical  News,  Oct.  12,  1889,  p.  25. 

11.  ELLIOT.     New   York  Medical  Journal,  April,    1887. 

12.  GILCHRIST.     Johns  Hopkins  Report.     Volume  i.,  p.  365. 

13.  BROOKE.     British  Journal  of  Dermatology,  1892,  p.  128. 

14.  BURI.     Monatshefte  /.,  prak.  Derm.  September  i,   1891. 

15.  BAZIN.     Affections  Cutanees  Arthritiques,   1862. 

1 6.  UNNA.     Histopathology,    1894. 


DERMATITIS  COCCIDIOIDES 
BY  DR.  AUGUSTUS  RAVOGLI,  OF  CINCINNATI 

When  it  was  ascertained  by  Perroncito  and  later  by  Israel 
and  Ponfick,  that  the  presence  of  the  streptothrix  bovis  or 
actinomyces  was  the  cause  of  the  disease,  actinomycosis,  af- 
fecting animals  and  man,  a  large  field  for  research  was  opened, 
and  other  diseases  were  found  resulting  from  the  introduction 
in  the  skin  of  infectious  parasites  of  a  higher  order.  In  fact, 
Poncet  and  Dor  showed  that  madura-foot  was  due  to  a  parasite, 
the  streptothrix  maduras.  The  botryomyces  was  found  in  the 
horse  and  from  it  was  communicated  to  man. 

To  the  researches  of  Busse  and  Gilchrist  we  owe  the  dis- 
covery of  parasites  resembling  yeast  as  a  cause  of  the  peculiar 
alterations  in  the  diseased  skin.  They  were  included  in  the 
group  of  blastomycetes. 

To  the  studies  of  Douglass  W.  Montgomery  has  to  be 
credited  the  distinction  of  another  form  belonging  to  the 
same  group,  namely,  dermatitis  coccidioides,  under  which  we 
class  our  case. 

On  November  18,  1905,  there  came  under  our  observation 
an  interesting  case  with  cutaneous  lesions  of  long  standing 
and  obscure  nature.  The  man,  J.  Z.,  was  then  51,  married, 
with  two  healthy  children.  He  had  always  been  in  good 
health ;  no  history  of  syphilis  or  tuberculosis  was  in  his  family. 
He  was  a  blacksmith  and  a  foundry  man  by  trade.  His  work 
necessitated  putting  his  hands  and  arms  in  the  fertilizer,  made 
of  crushed  and  pulverized  bones,  which  is  used  in  the  foundries 
to  put  around  the  moulds  to  hold  them  steady  for  the  iron 
casting.  He  referred  all  his  troubles  to  an  attack  of  grippe, 
which  he  had  had  two  years  previously.  He  first  noticed  that 
the  skin  of  his  hands  and  arms,  especially  on  the  extensor 
surface,  was  rough,  hard,  and  scaly,  and  at  the  same  time 

427 


428  SIXTH  INTERNATIONAL 

troubled  him  with  unbearable  itching.  Then  papules  ap- 
peared all  over  his  legs,  which  were  red  and  swollen,  suppu- 
rated, and  soon  were  covered  with  thick  crusts.  This  peculiar 
eruption  had  in  a  short  time  invaded  the  whole  extensor 
surfaces  of  both  legs  and  feet.  In  different  places  round 
ulcerations  were  formed,  with  infiltrated  edges  of  a  bluish 
red  color,  with  cauliflower-like  granulations  protruding  from 
the  honeycombed  floor  of  the  ulcer. 

The  condition  of  the  epidermis  of  the  fingers  and  the 
hands  grew  much  worse,  and  diffuse  ulcerations  were  formed 
in  the  interdigital  spaces,  near  the  finger  nails  and  around 
the  wrists,  while  the  eruption  extended  to  the  arms.  The 
ulcers  were  round,  somewhat  irregular,  resulting  from  the 
coalescence  of  many  ulcerated  points. 

Five  months  later  the  pustules  invaded  the  back  of 
the  head,  neck,  and  auricles,  and  only  recently  a  patch  had 
occurred  on  his  nostrils  involving  the  skin  and  the  mucous 
membrane. 

The  affected  skin  was  covered  with  yellow  crusts,  dry 
and  firmly  adherent.  In  some  parts  they  covered  a  nearly 
normal  epidermis,  and  over  the  deeper  ulcerations  they  were 
bulky.  From  these  lesions  oozed  a  fluid  and  viscid  secretion 
with  an  offensive  odor. 

When  the  patient  called  the  first  time,  the  whole  skin 
of  the  hands  and  arms  was  scaly,  infiltrated  and  thickened 
to  such  an  extent  that  he  could  not  open  or  close  his  hands. 
Several  fingers  showed  extensive  ulcerations  on  their  dorsal 
and  interdigital  surfaces.  The  nails  were  dry,  chalky,  and 
brittle.  Extensive  round  ulcerations,  with  thick  edges,  were 
seated  on  both  wrists,  on  the  external  surface  of  the  carpo- 
ulnar  region. 

In  order  to  establish  a  diagnosis,  a  piece  of  crust  crushed 
with  water  was  placed  under  the  microscope.  It  showed 
an  enormous  quantity  of  small  round  bodies,  which  greatly 
resembled  coccidia,  and  for  this  reason  we  called  the  disease 
dermatitis  coccidioides. 

Pieces  of  the  crusts  and  the  secretion  from  the  pustules 
were  inoculated  on  maltose-agar  in  Erlenmeyer  flasks,  and 
a  luxuriant  mouldy  growth  was  obtained.  This  showed, 


DERMATOLOGICAL  CONGRESS  429 

under  the  microscope,  spores,  resembling  those  which  we  had 
found  in  the  fresh  state. 

They  were  round,  had  thick  capsules,  and  contained  a 
granular  substance.  The  bottom  of  the  culture  showed  a 
thick  vegetation  of  mycelia  with  strong  articulated  filaments 
and  large  spores. 

It  was  of  interest  to  note  that  in  the  smear-preparations, 
when  mounted  in  Canada  balsam,  the  spores  had  all  disap- 
peared, while  on  the  dry  glass  around  the  balsam  they  were 
quite  numerous. 

This  observation  prompted  our  therapeutic  application, 
namely,  after  bathing  the  diseased  skin  with  a  i  to  1000 
solution  of  bichloride  of  mercury,  we  had  it  covered  with 
Peruvian  balsam  in  castor  oil.  Under  this  treatment  the 
ulcerations  and  the  pustules  healed  up  and  the  skin  returned 
to  its  normal  condition. 

The  patient  then  returned  to  his  occupation.  The  cure, 
however,  did  not  last  long,  for  after  a  few  months,  on  Novem- 
ber 19,  1906,  he  came  back  with  more  lesions  on  his  legs, 
especially  around  the  knees.  He  was  treated  again,  the  erup- 
tion almost  entirely  disappearing,  but  he  had  lost  flesh,  had 
frequent  attacks  of  fever,  and  had  become  very  weak  mentally. 
He  remained  under  our  treatment  until  the  eruption  had 
healed  and  then  returned  home.  He  died  on  May  30,  1907, 
his  physician  giving  the  diagnosis  of  consumption.  While 
the  patient  was  under  our  treatment  he  also  took  large  doses 
of  iodide  of  potassium,  from  which  no  benefit  was  derived, 
so  far  as  the  general  symptoms  were  concerned. 

Histology. — A  piece  of  the  ulcerated  skin  was  removed 
from  the  knee,  and  hardened  in  alcohol.  It  showed  the 
horny  layer  of  the  epidermis  to  be  first  affected  by  the  coccidia. 
They  insinuate  themselves  between  the  layers  and  detach 
the  cells,  which  are  then  reduced  to  hard  dry  scales.  The 
spores  are  produced  in  enormous  numbers.  The  cells  of  the 
deeper  layers  of  the  epidermis  do  not  remain  indifferent  to  the 
invasion  of  the  foreign  elements,  being  greatly  enlarged, 
thickened,  and  hypertrophic.  In  some  places  the  epidermic 
cells  appear  to  be  multiplying  and  surrounding  the  coccidia 
by  pearl-like  formations,  which  recall  the  pearls  found  in 


43o  SIXTH  INTERNATIONAL 

cancer.  Among  the  epithelial  cells  are  polynuclear  leucocytes 
with  coccidia  and  detritus,  and  often  also  giant  cells,  some 
of  them  containing  the  organisms, — demonstrating  their 
phagocytic  properties.  In  other  places  the  coccidia  are 
forcing  their  way  through  the  epidermis  and  have  formed 
wedge-like  masses  penetrating  the  deeper  layers.  The  irri- 
tation caused  by  the  presence  of  the  coccidia  is  responsible 
for  the  epidermic  proliferation  and  the  hypertrophy  of  the 
connective  tissue  elements  of  the  papillae. 

Plasma  cells,  arranged  in  dense  rows,  are  remarkable  for 
their  number.  There  are  present  also  numerous  small  ab- 
scesses filled  with  remains  of  degenerated  cells,  detritus,  and 
coccidia. 

The  coccidia  may  also  invade  the  cutis  by  the  way  of  the 
hair  follicles.  Our  microscopical  specimens  show  them  in- 
vading the  follicle  of  the  hair  and  through  its  shaft  entering 
the  meshes  of  the  derma.  The  latter  is  infiltrated  with  the 
organisms  and  resembles  somewhat  the  disposition  of  the 
infiltrating  elements  in  cutaneous  cancer.  The  coccidia  are 
found  between  the  connective  tissue  of  the  skin  and  in  the 
glands;  the  elastic  fibres  have  to  a  great  extent  disappeared. 

The  case  as  reported,  with  the  presence  of  coccidia  in  the 
different  layers  of  the  skin,  shows  that  these  micro-organisms 
are  the  morbid  factor  producing  the  disease. 

This  subject  was  elucidated  by  the  researches  of  Busse  1 
and  Gilchrist 2  and  an  etiological  relationship  established 
between  the  parasites  and  the  diseased  skin.  The  organisms 
were  called  blast omycetes,  and  the  skin  affection  blast o- 
mycosis. 

After  the  exhaustive  works  of  Buschke3  and  later  of 
Friedrich  Krause, 4  in  which  the  literature  on  the  subject  of 
blastomycosis  is  reviewed,  it  would  be  superfluous  to  return 
to  the  same  cases  again.  We  can  say,  however,  that  many  of 

1  BUSSE,  O.     "Die  Hefen  als  Krankheitserreger. "     Arch.  f.  Derm,  und 
Syph.,  Bd.  47. 

2  GILCHRIST,  T.  C.     The  Johns  Hopkins  Hospital  Reports,  1896. 

3  BUSCHKE,  A.     "Die    Blastomykose."     Arch.    f.   Derm,   und    Syphilis, 
Bd.  68-69,  J  903— 1904. 

4  KRAUSE,    F.     "Die  sogennante  Blastomykose    der    Haut. "     Monats- 
hefte  f.  prakt.  Derm.,  Bd.  41,  No.  4,  1905. 


DERMATOLOGICAL  CONGRESS  431 

these  cases  have  died  and  that  the  internal  organs  were  affected 
with  metastatic  foci,  containing  the  same  parasitic  elements. 

In  all  the  cases  the  parasites  had  gained  an  entrance 
through  the  skin.  The  latter  was  infiltrated  with  yeast  cells 
and  riddled  with  abscesses.  Giant  cells  were  present  in  the 
papillary  layer,  and  the  epidermis  was  proliferated. 

In  the  report  by  Curtis,1  of  Lille,  the  affection  occurred 
in  the  form  of  large  nodes  resembling  sarcomatous  tumors, 
which  were  found  to  contain  the  yeast  elements.  This  patient 
died  one  year  later  with  nervous  symptoms. 

Roncali2  referred  to  a  case  of  an  adenocarcinoma  of  the 
intestine  in  which  yeast  elements  were  present  and  which  had 
nothing  characteristic  of  a  carcinomatous  nature.  These 
parasitic  elements  were  thought  to  be  a  form  of  saccharomyco- 
sis,  which  localizes  at  first  in  the  skin,  and  then  by  metas- 
tasis invades  the  internal  organs. 

It  so  happened  that  the  so-called  protozoic  diseases  of 
Posadas,  Wernicke,  Rixford,  Gilchrist,  D.  W.  Montgomery, 
and  others,  Busse's  and  Curtis's  saccharomycosis  hominis, 
and  Gilchrist 's,  Hyde's,  and  F.  H.  Montgomery's  blastomycetic 
dermatitis  came  to  be  considered  as  various  manifestations 
of  the  same  disease.  In  the  opinion  of  Stelwagon,3  the  or- 
ganisms which  have  been  isolated  in  the  various  cases,  although 
they  differ  in  minor  respects,  morphologically  and  biologically 
are  so  closely  related  as  to  justify  their  classification  under 
one  group.  The  yeast  elements  can  grow  in  the  skin  and 
at  times  produce  a  strong  inflammatory  reaction  with  the 
formation  of  giant  cells,  while  at  other  times  they  may  cause 
only  a  limited  tissue  reaction  as  in  other  mycoses. 

D.  W.  Montgomery,  A.  Ryfkogel,  and  H.  Morrow4  have 
strongly  contended  that  dermatitis  coccidioides  should  be 

»  CURTIS,  F.  "A  propos  des  parasites  du  cancer."  Compt.  Rend.de  la 
Soc.  de  Biologie,  1899,  p.  191. 

2  RONCALI.     "Die   Blastomyceten   in   den   Sarcomen."     Zentralblatt  /. 
Bakt.  und  Parasitenkunde,  Bd.  xviii.,  1895. 

3  STELWAGON,  H.  W.     Treatise  on  Diseases  of  the  Skin,  p.  1072. 

4  MONTGOMERY,  RYFKOGEL,  and  MORROW.      "Dermatitis  Coccidioides." 
Journ.  Cutan.  Dis.,  Jan.,  1903. 

MONTGOMERY  and  MORROW.  "Reasons  for  Considering  Dermatitis 
Coccidioides  an  Independent  Disease."  Ibid.,  Aug.,  1904. 


432  SIXTH  INTERNATIONAL 

considered  an  independent  disease,  distinct  from  blast omycosis 
on  account  of  its  different  clinical  features  and  biological 
properties  of  the  fungus.  That  of  dermatitis  coccidioides 
grows  by  endogenous  spore  formation,  while  that  of  blast o- 
mycosis  grows  by  budding. 

Buschke,  too,  would  be  more  inclined  to  consider  blasto- 
mycosis  as  resulting  from  another  order  of  parasite,  more 
closely  resembling  the  oidion,  and  he  classified  it  as  oidio- 
mycosis.  The  difference  between  the  two  types,  according 
to  Buschke,  would  be  in  their  clinical  manifestations,  since 
in  blastomycosis  there  are  formed  small  tumors  of  the  skin 
which  become  ulcerated,  and  infection  is  often  carried  to  the 
lymphatic  glands,  while  dermatitis  coccidioides  begins  as  a 
diffuse  infiltration  of  the  skin,  with  small  abscesses  and  papil- 
lary growths  surrounded  by  an  area  of  infiltration  showing 
a  tendency  to  progression. 

Buschke,  D.  W.  Montgomery,  and  ourselves  have  found 
also  a  therapeutical  difference:  in  the  first  the  internal  use 
of  the  potassium  iodide  is  beneficial,  while  in  the  second  it  is 
not. 

The  blastomycotic  affection  begins  as  a  spot,  or  as  a  group 
of  papules,  or  as  nodules  or  pustules,  and  from  the  initial  forms 
an  infiltrated  base  is  developed  which  proliferates  in  a  warty 
manner  resembling  somewhat  tuberculosis  verrucosa  cutis 
or  cauliflower-carcinoma.  The  central  portion  softens,  form- 
ing abscesses.  The  color  of  the  affection  is  brown  or  bluish 
and  cyanotic,  the  abscesses  and  the  resulting  ulcerations 
discharge  freely,  and  with  a  little  pressure  small  drops  of  a 
purulent  substance  can  be  squeezed  out.  Ulcers  soon  form 
and  the  lymph  vessels  and  glands  are  involved  early.  In  our 
case,  however,  we  had  a  diffuse  infiltration  of  the  skin  with 
superficial  papillary  nodules  and  a  conglomeration  of  small 
abscesses.  The  spores  contained  in  the  secretion  are  capable 
of  inoculating  the  disease  in  other  places. 

Subjective  symptoms  are  usually  those  of  inflammation 
of  the  skin.  In  our  case  the  patient  was  suffering  from  an 
unbearable  itching. 

The  extension  of  the  disease  is  in  a  chronic  way,  taking 
months  and  years,  and  it  can  be  mistaken  for  tuberculosis 


DERMATOLOGICAL  CONGRESS  433 

verrucosa  cutis,  acne  abscedens,  or  lues.  At  times  there  are 
acute  recrudescences,  accompanied  by  mild  fever  and  malaise. 
In  the  beginning  there  are  no  systemic  troubles,  but  gradually 
the  disease  metastasizes  to  the  internal  organs — lungs,  liver, 
kidneys,  periosteum,  serous  membranes — and  then  the  symp- 
toms assume  a  much  more  serious  aspect.  The  patient  grad- 
ually becomes  weak,  has  fever,  an  irregular  cachexia  and 
mental  derangements,  the  disease  terminating  in  death. 

In  the  blastomycotic  form  recoveries  have  been  claimed, 
but  in  dermatitis  coccidioides  it  seems  that  no  case  has  so 
far  recovered.  The  disease  apparently  has  a  deleterious 
influence  on  the  nervous  functions.  In  the  subject  of  our 
study  and  in  another  of  botryomycosis  the  psychical  functions 
of  the  patients  were  greatly  impaired. 

The  histological  examination  has  shown  in  both  affections 
great  epidermic  hyperplasia  and  groups  of  epithelial  cells 
recalling  the  cancer  pearls.  Miliary  abscesses  are  present 
as  well  as  an  inflammatory  infiltration  of  leucocytes,  eosino- 
philes,  and  plasma  cells.  In  the  abscesses  are  found  groups 
of  spores  with  a  double  contour.  The  presence  of  giant  cells 
shows  the  introduction  of  the  foreign  elements. 

It  is  indeed  an  attack  of  saprophytes  on  the  tissues  of  the 
skin.  These  saprophytes  are  cultivated  on  the  culture  media 
of  the  yeast,  as  glycerin-agar  and  maltose-agar,  where  they 
vegetate  very  luxuriantly.  It  seems  that  they  need  sugar 
for  their  development.  In  the  culture  they  show  strong 
articulated  mycelial  threads  with  short  sprouts  from  their 
sides. 

Etiology. — In  the  case  of  Buschke,  the  remarkable  etio- 
logical  point  was  that  the  man  handled  corn  covered  with 
brown  powder.  The  corn  was  affected  with  smut  and  several 
horses  that  had  eaten  it  had  died.  Hyde  refers  to  the 
frequency  of  blastomycosis  in  individuals  who  handle 
manure.  In  the  case  of  D.  W.  Montgomery  the  man  had 
often  slept  in  box-cars  where  moulds  and  dirt  are  prone  to 
accumulate.  In  my  case  the  man  had  his  hands  in  the  fer- 
tilizer, which  is  made  by  drying  the  carcasses  of  animals 
and  then  pulverizing  them.  A  little  of  this  powder  examined 
under  the  microscope  was  found  to  contain  spores  which  bore 

VOL.  i.— 18 


434  SIXTH  INTERNATIONAL 

a  great  resemblance  to  those  found  in  the  diseased  skin.  Cul- 
tures made  with  the  same  fertilizer  powder  after  twenty  hours 
produced  an  abundant  vegetation  of  moulds.  These  were 
transplanted  to  a  tube  of  nutrient  gelatine  which  soon  became 
turbid,  liquefied,  and  contained  masses  of  mould.  Under  the 
microscope  were  seen  a  great  many  spores  with  double  contour, 
some  budding.  A  small  quantity  of  the  liquefied  gelatine 
was  injected  under  the  skin  of  a  guinea-pig,  which  twenty-six 
hours  later  died.  Its  blood  was  fluid  and  dark  and  contained 
spores  of  the  mould. 

Sanfelice  1  isolated  from  the  juice  of  fruits  a  yeast  which 
he  called  saccharomyces  neoformans,  which,  inoculated  into 
small  animals,  caused  morbid  symptoms  and  death.  Lydia 
Rabinowitsch 2  found  seven  varieties  of  yeast,  which  produced 
morbid  symptoms  in  white  mice  and  rabbits.  Mafucci  and 
Sirleo3  isolated  a  variety  of  yeast  which  is  pathogenic  for  the 
guinea-pig. 

With  the  inoculation  of  all  these  pathogenic  yeasts  there 
have  been  produced  infiltrations  and  ulcerations  of  the  skin, 
with  subsequent  involvement  of  the  lymph  glands  and  internal 
organs.  They  have  given  origin  also  to  tumors  of  the  sarcoma 
type  which  are  formed  by  the  yeast  cells. 

The  moulds  act  on  the  animal  as  morbid  elements.  Some 
moulds  inoculated  into  the  tissues  do  not  produce  a  local 
reaction  at  the  place  of  inoculation,  but  they  soon  develop 
in  the  fluids  of  the  tissues  and  in  the  blood  when  they  prove 
fatal.  In  other  instances  the  mould  may  remain  limited  to 
the  place  of  inoculation  and  the  affected  patch  can  be  removed 
surgically,  recovery  following,  but  usually  the  spores  are 
taken  up  by  the  lymphatics  and  by  the  lymph  glands,  or  by 
infection  through  the  blood  are  carried  to  the  internal  organs 
where  infiltrated  nodules  and  suppuration  are  produced. 

1  SANFELICE,  F.  "Contribution  a  la  morphologic  et  a  la  biologie  des 
blastomycetes  qui  se  developpent  dans  les  successeurs  des  divers  fruits. " 
Ann.  de  Micrographie,  1895,  No.  10. 

3  RABINOWITSCH,  L.  "  Untersuchungen  fiber  pathogene  Hefearten. " 
Quoted  by  Buschke. 

3  MAFUCCI,  A.,  and  SIRLEO,  L.  "  Osservazioni  ed  esperimenti  intorno  ad 
un  blastomycete  patogeno  con  inclusione  dello  stesso  nelle  cellule  dei  tessuti 
patogeni."  IlPoliclinico,  1905,  p.  138. 


DERMATOLOGICAL  CONGRESS  435 

In  Ward  C  of  the  Cincinnati  City  Hospital  we  have  still 
under  our  care  a  somewhat  similar  case  of  dermatitis  coc- 
cidioides,  in  a  colored  man  who  for  months  had  been  working 
in  the  sewers  and  wearing  mouldy  boots  during  this  time. 
He  was  covered  with  pustules  and  small  abscesses  from  his 
feet  to  his  thighs.  The  contents  of  the  pustules  showed  a  great 
many  round  coccidia-like  bodies.  All  pustules  and  abscesses 
when  healed  leave  deep  whitish  scars. 

According  to  the  experiment  of  Buschke,  the  yeasts  find 
their  way  into  the  system  through  the  skin  by  rubbing  or  by 
introduction  into  the  layers  of  the  epidermis  through  small 
wounds.  In  the  cases  referred  to  by  Marzinowski  and  Ba- 
grow1  the  blastomycetes  effected  an  entrance  through  the 
hair  follicles. 

In  both  our  cases  the  introduction  of  the  coccidia  occurred 
largely  through  the  hair  follicles.  The  introduction  may  also 
take  place  through  the  mucous  membranes  of  the  nose  and 
of  the  conjunctiva  and  even  through  the  mucous  membrane 
of  the  intestines.  There  was  found  also  an  embolic  condition 
produced  by  the  presence  of  the  blastomycetes  when  affect- 
ing the  peritoneum,  and  an  as  cites  chylosa  was  the  result  of 
the  occlusion  of  the  chylifera. 

Micro-organisms  of  a  higher  organization  belonging  to  the 
order  of  the  yeasts  or  of  the  moulds,  especially  under  certain 
conditions  of  the  atmosphere  and  of  the  animal  organism, 
morbidly  affect  the  animal  body  and  cause  local  alterations 
of  the  tissues  with  pus  formation.  A  blastomycetic  septicaemia 
as  a  result  of  metastasis,  with  growth  of  spores  in  the  blood 
and  in  the  fluids  of  the  tissues,  has  also  been  proved.  From 
the  deleterious  results  in  our  case  we  must  maintain  that 
a  blastomycotic  infection  occurs  along  with  alteration  of 
the  fluids  of  the  tissues,  which,  carried  in  the  circulation, 
affect  the  serum  of  the  blood,  as  in  any  other  infectious 
disease. 

That  the  physical  condition  of  the  individual  offers  more 
or  less  propitious  ground  for  the  development  of  these  patho- 

1  MARZINOWSKI  und  BAGROW.  "Die  Blastomyceten  und  ihre  Beziehung 
zu  Hautkrankheiten. "  Arch.  f.  Derm,  und  Syph.,  Bd.  86,  Nos.  i  and  a, 
1907,  p.  226. 


436  SIXTH  INTERNATIONAL 

genie  organisms  is  made  clear  by  the  observation  of  Ehrmann 1 
in  a  diabetic  workman  employed  in  a  yeast  factory,  who  was 
suffering  with  an  extensive  pustular  eruption.  In  the  pustules, 
yeast  cells  were  found,  which,  when  inoculated  in  the  same 
man,  produced  new  pustules,  but  when  inoculated  into  a 
healthy  man  gave  no  result. 

Recapitulating,  we  have  a  group  of  diseases  produced  by 
organisms  which  are  introduced  into  the  skin,  either  by  abra- 
sions or  by  the  natural  pores,  and  are  taken  from  animals, 
grains,  or  fertilizers. 

As  regards  their  nature,  they  are  infectious,  with  a  chronic 
course  which  lasts  for  months  and  years.  They  have  often 
shown  themselves  in  repeated  attacks,  and  the  first  place  to 
be  affected  is  the  skin,  in  which  the  affection  remains  localized 
for  a  long  time,  but  in  many  cases  soon  spreads  to  the  con- 
tiguous mucous  membranes,  and  later,  by  metastasis  through 
the  blood  or  through  the  lymph  channels,  affects  the  lungs, 
liver,  kidneys,  periosteum,  and  nervous  system.  The  ma- 
jority of  the  cases  terminate  fatally,  but  in  some  it  would 
appear  that  tuberculosis  assists  in  hastening  the  end. 

Owing  to  the  varieties  of  the  oidia,  clinical  differences 
arise,  and  although  the  types  are  related  among  themselves, 
as  at  first  maintained  by  D.  W.  Montgomery,  they  show  wide 
variations  nosologically  and  mycologically.  For  this  reason  and 
because  its  parasite  more  closely  resembles  a  coccidium,  we  have 
reported  our  case  under  the  name  of  dermatitis  coccidioides. 

Discussion 

DR.  DOUGLASS  W.  MONTGOMERY,  of  San  Francisco,  said  he  could 
not  make  out  the  coccidioides  organisms  in  the  microscopic  sections 
shown  by  Dr.  Ravogli.  The  organisms  in  granuloma  coccidioides 
specimens  are  very  distinct.  They  are  capsules  with  a  beautiful 
contour,  encasing  spherical  bodies. 

••EHRMANN,  quoted  by  Buschke,  L  c. 


DERMATOLOG1CAL  CONGRESS  437 

At  12  M.  the  President  announced  that  the  time  had 
arrived  for  the  executive  session.  At  this  time  it  was 
customary  to  elect  the  President  of  the  succeeding  Congress 
and  select  the  place  of  the  next  meeting.  This  was  the  only 
link  between  succeeding  sessions  of  the  Congress. 

PROF.  ROBERT  CAMPANA,  of  Rome,  Italy,  in  a  few  ap- 
propriate words,  named  Rome  as  the  next  place  of  meeting. 
He  thanked  his  colleagues  in  America  for  their  hospitality 
and  expressed  the  hope  that  Rome,  the  capital  of  the  world, 
would  be  selected  for  the  next  place  of  meeting,  and  that  he 
would  see  them  all  there. 

For  President  of  the  next  session  of  the  Congress,  Prof. 
Campana  proposed  the  name  of  Prof.  Thomas  De  Amicis,  of 
Naples,  Italy,  who  was  at  present  one  of  the  Honorary  Presi- 
dents of  the  Dermatological  Section  of  the  American  Medical 
Association.  The  time  of  the  next  Congress  was  to  be  desig- 
nated by  a  committee  appointed  by  the  new  President. 

DR.  J.  NEVINS  HYDE,  of  Chicago,  in  seconding  the 
nomination  of  Prof.  De  Amicis  as  the  President  of  the  next 
Congress,  and  Rome  as  the  place  of  the  next  meeting,  said  the 
opportunity  to  do  this  gave  him  much  pleasure,  as  he  had 
great  respect  for  his  colleagues  in  Italy.  He  had  a  vivid 
recollection  of  the  last  meeting  of  the  Congress  in  Berlin, 
when  he  presented,  on  the  part  of  the  American  Dermatological 
Association,  an  invitation  to  the  Congress  to  come  to  New 
York,  not  without  doubts  as  to  how  it  would  be  received. 
At  this  moment  our  good  friend  and  distinguished  colleague, 
Prof.  Neisser,  arose  and  most  cordially  seconded  the  invitation. 
It  was  with  great  pleasure,  Dr.  Hyde  said,  that  he  seconded 
the  nomination  made  by  Prof.  Campana. 

It  was  thereupon  unanimously  decided  that  Prof.  Thomas 
De  Amicis,  of  Naples,  Italy,  should  be  President  of  the  next 
Congress,  and  that  the  place  of  the  next  meeting  should  be 
Rome,  Italy. 

Adjournment  at  i  o'clock 

End  of  Third  Day 


FOURTH  DAY,  THURSDAY,  SEPTEMBER  i2TH 

CLINICAL  DEMONSTRATION  OF  CASES,  9-1 1  A.M. 

A  Case  for  Diagnosis:  Possibly  Lichen  Ruber  Acuminatus 
PRESENTED  BY  DR.  WILLIAM  B.  TRIMBLE,  OF  NEW  YORK 

The  patient,  a  woman,  aged  forty-seven;  single,  born  in 
United  States,  has  had  the  disease  for  twelve  years.  The 
family  history  was  negative.  She  had  several  brothers 
and  sisters,  all  of  whom  were  living  and  healthy,  with  no 
tendency  to  cutaneous  disease. 

The  affection  began  as  a  somewhat  generalized  papular 
eruption  which  itched  intensely.  It  progressed,  and  at  the 
time  of  presentation  the  whole  integument  was  affected. 
The  skin  was  dusky  red  in  color,  much  infiltrated  and 
abundantly  scaly;  the  scaling  was  branny  in  character.  On 
the  legs  could  be  seen  numbers  of  acuminate  papules;  but 
these  were  not  present  on  other  parts  of  the  body.  The 
forearm  showed  quite  a  marked  pigmentation,  with  some 
keratosis.  This  might  be  due  to  arsenic,  as  the  patient  had 
taken  this  drug,  for  long  periods  of  time,  during  the  last  ten 
years. 

Histopathology. — The  epidermis  was  somewhat  thickened, 
especially  the  granular  and  horny  layers.  The  former  was 
unusually  distinct  in  places,  containing  many  coarse  granules ; 
the  latter  showed  more  of  a  hyper-  than  a  parakeratosis, 
although  here  and  there  a  few  nuclei  could  be  distinguished. 

The  majority  of  the  rete  pegs  were  flattened  out.  There 
was  a  diffuse,  rather  dense  subepidermic  infiltration  of  round 
and  plasma  cells,  which  in  the  deeper  layers  of  the  cutis  had 
af  peri  vascular  disposition.  Some  of  the  vessels  showed  a 
marked  thickening  of  the  walls.  There  was  a  moderate  in- 
crease of  fibroblasts,  and  a  mucoid  degeneration  was  present 
about  the  coil  glands. 

438 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS        439 

A  Case  for  Diagnosis 

PRESENTED  BY  DR.  GEORGE  HENRY  Fox,  OF  NEW  YORK 
Male,  forty  years,  married;  U.  S. ;  physician.  Patient's  nose 
was  swollen  for  two  years,  following  explosion  of  an  alcohol 
lamp,  and  the  tip  was  drawn  in  as  a  result.  A  year  ago  a 
slight  injury  was  followed  by  exudation,  crusting,  and  moderate 
itching,  an  eczematous  condition  of  the  upper  lip.  There  was 
a  congenital  deformity  of  the  uvula.  Calomel  injections  and 
potassium  iodide,  150  grains  daily  for  six  weeks  had  little  if 
any  effect.  At  a  meeting  of  the  New  York  Dermatological 
Society  in  May,  1907,  the  diagnosis  of  syphilis  was  rejected. 
Some  thought  the  lesion  tuberculous.  Subsequent  micro- 
scopic examination  had  excluded  the  diagnosis  of  tuberculosis 
and  malignant  disease. 

DR.  S.  POLLITZER,  of  New  York,  said  that  rhinoscleroma  had 
been  suggested  in  Dr.  Fox's  case,  but  the  diagnosis  had  been 
rejected  on  the  results  of  a  biopsy. 

DR.  BOLESLAW  LAPOWSKI,  of  New  York,  said  he  thought  the 
lesion  was  of  specific  origin.  He  had  had  the  patient  under  his 
care  for  a  time,  and  marked  improvement  had  followed  the  use 
of  calomel  injections. 

DR.  H.  HALLOPEAU,  of  Paris,  suggested  animal  inoculation 
tests  to  help  clear  up  the  diagnosis. 

DR.  ALEX.  RENAULT,  of  Paris,  thought  the  lesion  was  the  result 
of  a  mixed  infection — syphilis  and  tuberculosis.  The  fact  that 
anti-syphilitic  treatment  had  had  no  effect  proved  nothing  to 
him. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  thought 
the  lesion  was  syphilitic.  He  recalled  a  somewhat  similar  case 
which  failed  to  heal  under  inunctions,  but  which  improved  after 
injections  of  albuminate  of  mercury.  He  also  suggested  the  old 
method  of  treatment  with  Zittmann's  decoction. 

DR.  Fox,  in  closing  the  discussion,  said  the  improvement  in 
the  lesion  after  the  use  of  calomel  injections,  to  which  Dr.  La- 
powski  had  referred,  had  been  very  slight  and  by  no  means  suffi- 
cient to  indicate  a  specific  origin  of  the  disease. 


440  SIXTH  INTERNATIONAL 

Case  of  Prurigo  Ferox  (Besnier's  Diathetic  Prurigo) 
PRESENTED  BY  DR.  JAMES  C.  JOHNSTON,  OF  NEW  YORK 
Man,  aged  forty-six.     When  first  seen  two  years  ago,  body 
was  covered  from  head  to  toe  by  the  eruption.     The  skin 
was  enormously  thickened,  pigmented  and  marked  by  scratch- 
ing.    The  patient  stated  that  he  had  not  been   free  from 
violent  itching  for  several  years.     Impetiginous  and  eczema- 
tous  complications  were  frequent.      A  process  of  papulation 
could  be  made  out  on  the  diffuse  infiltration  by  means  of  the 
scratched  tops  of  the  papules. 

Under  treatment  by  elimination  and  diet  the  eruption  sub- 
sided somewhat  and  the  discovery  was  made  that  relapse  begins 
with  an  cedematous  infiltration  covering  fairly  large  areas  on 
which  vesico-papules  appeared,  their  tops  being  immediately 
abraded  by  rubbing.  The  sites  of  election  were  face  and  flanks. 
After  reaching  a  certain  point,  regression  ceased  and  it  seemed 
impossible  to  influence  the  process  in  any  way  until,  acting  on 
a  theory  of  disturbance  in  the  intermediary  proteid  metabolism, 
extract  of  the  whole  fresh  thyroid  was  administered  hypo- 
dermatically.  Improvement  began  shortly  and  the  patient 
was  now  practically  well. 

Case  of  Prurigo  Ferox 

PRESENTED  BY  DR.  JAMES  C.  JOHNSTON,  OF  NEW  YORK. 
Man,  aged  fifty-six.     Lesions  to  all  intents  the  same  as 
in  the  preceding  case  except  that  they  were  confined  to  face, 
neck,  and  hands.     Under  diet,  tar  locally,  and  thyroid  nucleo- 
proteids,  the  condition  greatly  improved. 

(The  two  cases  are  reported  more  fully  in  the  paper  of 
Drs.  Johnston  and  Schwartz  in  the  Transactions  of  the 
Congress.) 

A  Case  of  Gangrene  of  the  Toes  Due  to  Syphilitic  Endarteritis,  Simulating 

Raynaud's  Disease 

PRESENTED  BY  DR.  HOWARD  Fox,  OF  NEW  YORK 

Patient,  set.  twenty-eight;  married;  U.  S. ;  electrician. 

Seven  years  ago  he  had  a  hard  genital  sore  lasting  a  month 

and   followed   by  general   eruption.     Wife   is   said  to  have 

contracted  the  disease  from  her  husband  three  months  later. 

Patient    practically    refused    treatment.      One    child    born 

before  the  disease  was  contracted  is  healthy.     Another  child 


DERMATOLOGICAL  CONGRESS  441 

born  after  disease  was  contracted  had  "snuffles"  and  sores 
on  the  feet  as  an  infant.  Wife  had  since  given  birth  to  an 
eight  months'  dead  child. 

Two  and  one  half  years  ago  all  the  toes  of  left  foot  (except 
fourth)  became  black  and  withered  and  were  amputated. 
Two  months  later  portions  of  great  and  first  toes  of  right 
foot  became  extremely  painful  and  black.  Two  years  ago 
symptoms  of  "dead  ringers"  in  first  and  second  ringers  of 
right  hand  and  fourth  and  fifth  of  left  hand.  Later  right 
unilateral  iridoplegia  which  persisted  to  present  time.  Urine 
showed  heavy  trace  albumin.  Although  case  had  been  con- 
sidered by  many  to  be  one  of  Raynaud's  disease,  the  demon- 
strator looked  upon  it  as  one  of  syphilitic  endarteritis  of 
the  peripheral  vessels  for  the  following  reasons:  History  of 
chancre,  followed  by  eruption  and  probable  infection  of  wife 
and  child,  lack  of  absolute  symmetry  in  the  "dead  fingers"; 
the  excruciating  pain;  the  unilateral  iridoplegia  and  almost 
complete  cure  under  antisyphilitic  treatment  (injections  of 
salicylate  of  mercury).  (Case  was  reported  in  Med.  Review 
of  Reviews,  May,  1907.) 

A  Case  of  Tuberculide 

PRESENTED  BY  DR.  BOLESLAW  LAPOWSKI,  OF  NEW  YORK 
Man,  forty-one  years  of  age,  tailor  by  occupation.  Ten 
years  ago  he  had  a  "pimple"  on  his  penis,  which  disappeared 
in  a  few  days.  He  did  not  remember  any  secondary  symp- 
toms on  either  skin  or  mucous  membranes.  The  present 
eruption  began  about  fourteen  years  ago  on  the  face,  coming 
and  going  and  spreading  gradually  downward;  his  body  was 
never  free  from  it  for  the  past  eight  or  ten  years.  Each  lesion 
began  as  a  "  pimple  "  with  a  white  centre,  from  which  serum 
or  matter  could  be  expressed.  If  not  scratched  the  papules 
dried  and  scabbed,  the  scab  falling  and  leaving  a  depressed 
opening;  there  was  no  itching.  The  eruption  was  scattered 
over  both  lumbar  regions  and  on  the  flexor  surfaces  of  the 
upper  and  the  lower  limbs  in  rings  and  half  rings,  which  on 
healing  left  pea-sized  scars,  without  any  pigmentary  border 
on  the  abdomen,  while  on  the  lower  extremities  there  were 
pigmentary  spots.  Some  had  dry  blood  scabs,  on  removal  of 
which  punched  out  bleeding  ulcers  appeared,  neither  deep 


442  SIXTH  INTERNATIONAL 

nor  dry  enough  for  a  tuberculide.  Several  months  ago  he 
had  an  urticarial  and  impetiginous  eruption,  which  gradually 
disappeared,  leaving  the  original  lesions  but  little  changed. 
The  patient  was  presented  before  the  Section  on  Dermatology 
of  the  New  York  Academy  of  Medicine  in  October,  1906,  with 
the  demonstrator's  diagnosis,  which  was  concurred  in  by  some 
of  the  members  present  while  others  regarded  it  as  a  syphilitic 
eruption.  Since  that  time  the  patient  had  been  treated  with 
inunctions,  injections  of  mercury  (salicylate  and  calomel),  and 
large  doses  of  potassium  iodide,  with  no  permanent  result.  The 
eruption  would  improve,  the  papulo-tubercles  would  be  absorb- 
ed, but  not  entirely,  and  at  the  same  time  a  new  eruption  would 
appear  running  its  course  and  leaving  scars.  Lately  atoxyl 
injections  were  tried  without  any  result. 

DR.  JOSEPH  ZEISLER,  of  Chicago,  thought  the  case  shown  by 
Dr.  Lapowski  belonged  to  a  class  of  cases  that  the  French  had 
designated  folliclis,  which  the  speaker  said  did  not  mean  much 
to  him. 

A  Case  of  Hillary  Tuberculosis  of  the  Skin  and  Mucous  Membrane 
PRESENTED  BY  DR.  BOLESLAW  LAPOWSKI,  OF  NEW  YORK 

R.  S.,  single,  twenty-two  years  old,  no  personal  history. 
The  internal  organs  were  normal  excepting  the  spleen  which 
was  slightly  enlarged.  Two  years  ago  a  small  tubercle  ap- 
peared on  the  right  lower  lip,  and  since  that  time  the  disease 
progressed  involving  the  skin  of  the  upper  lip,  right  cheek, 
chin,  and  mucous  membranes  of  the  mouth.  The  patient 
had  been  treated  before  he  came  under  the  care  of  the  demon- 
strator with  various  caustic  preparations  (the  visible  scars 
were  remnants  of  their  application) .  Since  then  a  creosote  and 
carbol  plaster  (Beiersdorf's)  was  used  and  internally  creosote 
pills. 

On  the  upper  lip,  chin,  lower  lip,  and  corners  of  the  mouth 
there  were  ulcers  of  various  sizes  from  a  pea  to  a  penny.  The 
floor  of  the  sores  was  studded  with  pinhead-sized  ulcers  covered 
with  grayish  discharge;  edges  raised  and  moth-eaten.  Among 
the  sores  were  scattered  scars  of  former  lesions.  In  the 
scar  tissue  were  pinhead-sized  tubercles. 


DERMATOLOGICAL  CONGRESS  443 

A  Case  of  Tuberculide 
PRESENTED  BY  DR.  BOLESLAW  LAPOWSKI,  OF  NEW  YORK 

Girl,  fourteen  years  old.  When  nine  months  old  she  had 
measles  (seen  by  Dr.  Koplik) .  At  the  same  time  she  developed 
on  her  nose  and  forehead  a  few  "pimples."  Three  months 
after  she  had  chicken  pox  (?)  on  the  face  and  extremities. 
A  little  later  diphtheria  (Koplik)  and  she  lost  at  that  time 
her  voice,  which,  however,  soon  after  returned.  At  six  she 
had  "pimples"  on  her  face  and  several  years  later  on  her 
hands.  At  that  time  the  school  doctor  cauterized  these  lesions, 
probably -with  carbolic  acid.  At  eleven  she  suffered  from  some 
fever  eruption  (scarlet).  Since  that  time  up  to  the  present 
she  has  never  been  entirely  free  from  an  eruption,  a  "  pimple" 
appearing  here  and  there,  which  the  patient  would  scratch 
and  after  a  few  weeks  it  would  disappear  leaving  a  scar. 
Scars  were  visible  on  her  face,  arms,  dorsal  aspect  of  both 
hands  and  scalp. 

On  dorsal  aspects  of  both  hands  and  extensor  surfaces  of 
both  forearms,  on  forehead  and  partly  on  the  chest,  were  pin- 
head-  to  millet-sized  tubercles  with  necrotic  centre  reaching 
down  deep  into  the  skin.  The  necrotic  cluster  was  sharply 
cut  out,  with  even  edges. 

A  Case  of  Pityriasis  Rubra  Pilaris  (Devergie) 
PRESENTED  BY  DR.  S.  POLLITZER,  OF  NEW  YORK 
Male,  aged  twenty-five,  born  U.  S.  of  German  parents. 
General  health  good.  Cutaneous  affection  was  present  since 
early  childhood  and  never  entirely  well  though  varying  in 
extent  at  times;  at  present  moderately  severe.  Had  been 
under  treatment  by  many  dermatologists  in  New  York  but 
disease  was  absolutely  refractory,  even  prolonged  X-raying  on 
selected  regions  being  without  any  effect.  Patient  had  been 
presented  before  the  American  Dermatological  Association 
and  the  New  York  Dermatological  Society  with  unanimity  of 
diagnosis.  It  was  regarded  as  a  typical  severe  case. 

PROF.  GAUCHER,  of  Paris,  said  the  long  duration  of  the  disease 
spoke  against  pityriasis  rubra  pilaris,  while  the  appearance  of 
the  fingers  and  nose  favored  it. 

PROF.  WOLFF,  de  Strasbourg,  a  dit  qu'il  conside*rait  1'affection 


444  SIXTH  INTERNATIONAL 

comme  tin  pityriasis  rubra  pilaire.  La  longtie  dure'e  de  la  maladie 
n'entrait  pas  en  ligne  de  compte.  II  a  eu  deux  cas  qui  ont 
present^  une  dure'e  analogue.  L'un  des  cas  e*tait  encore  alors  en 
traitement  a  la  Clinique  de  Strasbourg.  II  s'agissait  d'une  jeune 
fille  chez  laquelle  la  maladie  avait  commence*  a  1'age  de  sept  ans 
et  qui  avait  alors  vingt  six  ans,  ce  qui  fait  une  dure'e  de  dix  neuf 
ans. 

DR.  WILLIAM  A.  PUSEY,  of  Chicago,  said  that  as  Dr.  Pollitzerhad 
asked  for  therapeutic  suggestions,  he  wished  to  refer  to  a  practically 
identical  case  of  pityriasis  rubra  pilaris  in  which  very  assiduous 
treatment  with  X-rays  carried  on  for  a  period  of  about  a  year  had 
had  no  beneficial  effect. 

DR.  ARTHUR  WHITFIELD,  of  London,  said  he  was  not  quite 
willing  to  accept  the  diagnosis  in  this  case.  On  the  back,  es- 
pecially, as  well  as  in  other  locations,  the  lesions  showed  a  typical 
gyrate  and  ringed  extension.  He  knew  of  no  case  of  pityriasis 
rubra  pilaris  that  had  ever  been  described  with  such  a  method  of 
extension.  In  Dr.  Pollitzer's  case  the  palms  were  absolutely 
unaffected,  whereas  in  pityriasis  rubra  pilaris  the  palms  as  well  as 
the  nails  were  usually  involved.  The  only  locations  that  were 
suggestive  of  pityriasis  rubra  pilaris  were  the  phalanges  on  their 
dorsal  aspect,  and  even  then  it  was  a  diffuse  scaling  with  some 
blackening  of  the  follicles  rather  than  a  primary  follicular  hyper- 
keratosis,  and  if  one  took  into  consideration  the  very  long  duration 
of  the  disease  and  the  various  methods  of  treatment  that  the 
patient  had  undergone,  the  appearance  of  the  lesions  was  not 
surprising.  The  speaker  said  he  regarded  the  case  as  one  of  in- 
veterate psoriasis  occurring  in  a  very  young  child  and  lasting  a 
long  time. 

DR.  JOSEPH  ZEISLER,  of  Chicago,  in  reply  to  Dr.  Whitfield,  said 
that  in  his  opinion  the  case  shown  by  Dr.  Pollitzer  was  an  abso- 
lutely classical  one  of  pityriasis  rubra  pilaris  of  Devergie.  The 
appearance  of  the  end  of  the  nose  was  absolutely  typical  of  that 
disease,  and  he  considered  the  diagnosis  of  psoriasis  untenable 
for  a  single  moment. 

A  Case  of  Lichen  Planus  Annularis 

PRESENTED  BY  DR.  JEROME  KINGSBURY,  OF  NEW  YORK 
Patient  was  a  school  girl  nine  years  of  age;  born  in  U.  S. 
of  Russian  parentage.     She  was  anaemic,  nervous,  and  poorly 
developed. 


DERMATOLOGICAL  CONGRESS  445 

The  eruption  was  quite  general  and  of  eight  weeks'  dur- 
ation. There  were  many  characteristic  lichen  papules  on 
the  forearms,  buttocks,  and  thighs  but  the  lesions  of  interest 
were  annular  ones  found  on  the  trunk  and  upper  extremities. 
These  varied  in  diameter  from  i  cm.  to  4  cm.  The  largest 
were  on  the  chest  and  abdomen  and  showed  some  fine  grayish 
scaling.  In  addition  to  the  skin  lesions  there  were  patches 
on  the  oral  and  vaginal  mucosa. 

PROF.  WOLFF,  of  Strassburg,  thought  that  in  the  case  shown 
by  Dr.  Kingsbury  there  was  no  other  diagnosis  possible  than 
lichen  ruber  annularis.  The  only  diseases  to  be  differentiated  were 
granuloma  annulate  and  porokeratosis,  but  the  presence  of  well- 
characterized  white  papules  on  the  inner  surface  of  the  cheeks 
determined  the  diagnosis  of  lichen  planus. 

A  Case  of  Scleroderma  and  Sclerodactylitis 
PRESENTED  BY  DR.  J.  A.  FORDYCE,  OF  NEW  YORK 

M.  S.,  aet.  fifty-three,  widow,  born  in  Russia.  The  patient 
had  been  under  observation  since  May,  1906.  When  first 
seen,  she  gave  the  following  history:  The  disease  began  four 
and  one-half  years  previously  by  a  "tightening"  and  glazed 
appearance  of  the  skin  on  the  backs  of  the  fingers,  the  hands 
and  lower  third  of  the  forearms.  Six  months  later  the  con- 
tractures  took  place,  beginning  with  the  ring  ringer  of  the  left 
hand.  Lesions  about  the  nails  soon  followed,  resulting  in 
an  ulcerating  paronychia,  one  ringer  after  another  becoming 
affected  accompanied  by  considerable  pain  and  soreness. 
A  radiogram  made  shortly  after  her  admittance  to  the  clinic 
showed  atrophy  of  the  terminal  phalanges.  The  skin  covering 
the  fingers,  hands,  and  lower  third  of  forearms  was  atrophic 
and  closely  adherent  to  the  underlying  structures,  presenting 
a  typical  picture  of  scleroderma. 

In  addition  to  the  above,  the  patient's  legs  were  swollen 
from  hard  oedema,  her  toe  nails  presented  dystrophic  changes, 
and  on  the  plantar  surface  of  the  left  great  toe,  there  was  the 
suggestion  of  a  beginning  perforating  ulcer.  Over  her  fore- 
head and  malar  bones  the  skin  was  drawn  and  tight  and  on 
her  occiput  there  was  a  round  red  scaling  lesion  about  the 
size  of  a  silver  dollar  which  resembled  lupus  erythematosus. 


446  SIXTH  INTERNATIONAL 

A  Case  of  Acne  Vulgaris  and  Adenoma  Sebaceum  of  the  Chest 

PRESENTED  BY  DR.  J.  A.  FORDYCE,  OF  NEW  YORK 
The  patient  was  a  young  man,  about  twenty-one  years  of 
age,  who  had  a  congenital  heart  lesion,  giving  rise  to  per- 
sistent cyanosis.  He  had  a  well-marked  acne  of  the  face  and 
trunk.  In  addition  to  the  multiform  lesions  of  acne,  he  had 
an  enormous  number  of  milium-like  lesions  over  the  chest, 
back,  and  face.  They  were  larger,  however,  than  the  usual 
milium,  and  each  had  a  central  punctum  similar  to  those  seen 
in  adenoma  sebaceum.  The  lesions  were  unlike  those  seen 
in  the  usual  type  of  the  so-called  adenoma  sebaceum  of  the 
face,  where  they  are  more  or  less  crimson  in  color  due  to  the 
telangiectases.  Here  they  were  more  translucent  and  different 
from  the  dead-white  of  the  ordinary  milium  lesion.  The 
histological  examination  showed  them  to  be  made  up  of 
sebaceous  glands  much  increased  in  number  over  their  normal 
condition. 

DR.  A.  R.  ROBINSON,  of  New  York,  said  he  did  not  think  the 
milium-like  lesions  on  the  chest  were  examples  of  adenoma 
sebaceum.  He  regarded  the  lesions  as  follicle  horn  cysts  or  as 
milium  bodies  formed  from  an  outgrowth  of  the  outer  follicle 
sheath  in  the  upper  third  of  the  follicle. 

Two  Cases  of  Lupus  Erythematosus 
PRESENTED  BY  DR.  S.  POLLITZER,  OF  NEW  YORK 
These  cases  with  lesions  of  the  face,  almost  cured,  were 
presented  to  show  the  effect  of  treatment,  three  and  five 
months,  respectively,  with  five  per  cent,  salicylic  and  soap-lead 
plaster. 

A  Case  of  Argyria 

PRESENTED  BY  DR.  DAISY  M.  ORLEMAN-ROBINSON,  OF  NEW  YORK 
Female,  age  fifty-four  years,  brunette,  tall  and  stout. 
She  was  treated  for  a  catarrhal  condition  of  her  throat  four 
and  a  half  years  ago,  once  every  two  weeks  for  a  period  of  two 
months  with  a  solution  of  nitrate  of  silver  in  the  form  of  a 
spray,  five  grains  to  the  ounce.  She  continued  this  treatment 
herself  daily  until  she  came  under  the  demonstrator's  observa- 
tion. One  ounce  of  the  solution  lasted  one  month.  She  first 
noticed  a  discoloration  of  the  skin  two  years  ago.  The  dis- 


DERMATOLOGICAL  CONGRESS  447 

coloration  when  shown  was  general  over  the  entire  body,  but 
most  marked  upon  the  parts  exposed  to  the  light  and  of  a 
bluish-gray  shade.  It  was  lighter  in  color  upon  the  lower 
extremities.  The  mucous  membrane  of  the  mouth  had  a 
decided  bluish  tinge.  The  discoloration  on  the  gums  was  less 
marked.  The  mucous  membrane  of  the  vagina  and  the 
rectum  was  similarly  discolored.  Microscopical  examination 
of  sections  from  the  shoulder  showed  the  pigment  granules 
especially  present  in  the  dense  connective  tissue  (basement- 
like  membrane)  of  the  sweat  gland  coil,  and  to  a  less  extent 
in  a  similar  situation  in  the  excretory  duct.  The  pigment 
was  also  quite  abundant  in  the  perimysium  of  the  unstriped 
muscle  bundles.  A  slight  amount  of  pigment  was  also  present 
in  the  lymph  spaces  in  the  upper  part  of  the  corium.  Pigment 
was  absent  in  all  of  the  epithelial  structures. 

A  Case  of  Xanthoma  Multiplex 

PRESENTED  BY  DR.  JAMES  MACFARLANE  WINFIELD,  OF  BROOKLYN 
Female  born  in  the  United  States ;  Russian  Hebrew  parents. 
Nothing  of  interest  in  the  family  history-  Personal  history — 
was  a  fine  baby  with  a  clear,  healthy  skin,  and  with  the  ex- 
ception of  measles  had  never  been  ill;  bowels  regular,  never 
been  jaundiced;  when  the  child  was  four  months  old,  the 
mother  stated  that  she  noticed  a  few  faded  brownish  macules 
about  the  neck,  a  month  later  small  reddish  papules  appeared 
in  the  centre  of  the  macules;  they  were  clear  red  and  at  no 
time  contained  any  fluid;  the  eruption  was  thought  to  be 
prickly  heat  and  was  treated  accordingly;  the  papules  grad- 
ually increased  in  size,  became  less  hard,  the  red  color  fading 
into  yellow  or  orange  yellow;  the  skin  over  the  spots  became 
soft,  wrinkled  and  flabby,  the  course  of  development  from 
the  primary  macule  to  the  full-grown  xanthomatous  lesion 
taking  about  six  months.  The  eruption  involved  the  trunk, 
legs,  arms,  and  neck,  being  more  extensive  about  the  neck 
and  upper  part  of  the  trunk;  in  some  places  the  lesions  were 
closely  grouped ;  none  had  disappeared  and  new  ones  were  con- 
stantly developing.  The  child's  health  seemed  to  be  perfect ; 
no  enlargement  of  the  liver,  no  urticaria;  examination  of  the 
urine  negative. 


448  SIXTH  INTERNATIONAL 

Microscopical  examination  of  the  lesions  showed  them 
to  be  xanthoma. 

A  Case  of  Xanthoma  Tuberosum  Complicated  by  Diabetes 
PRESENTED  BY  DR.  HOWARD  Fox,  OF  NEW  YORK 
Mt.  forty;  widow;  born  in  Germany;  bath  attendant. 
The  eruption  first  appeared  about  nine  years  ago  on  the 
elbows.  A  year  and  a  half  ago  the  patient  noticed  a  single 
small  lesion  on  the  knee  and  four  years  ago  several  lesions 
on  the  thigh.  The  lesions  on  the  buttocks  appeared  recently. 
Three  years  ago  she  began  to  suffer  from  excessive  thirst  and 
appetite,  this  condition  persisting  till  a  year  ago.  During 
the  past  two  years  she  lost  twenty  pounds  and  felt  generally 
weak. 

The  elbows  showed  discrete  and  clustered  nodules  of 
typical  xanthoma  tuberosum.  On  the  buttocks  there  were 
about  fifteen  discrete,  yellowish  nodules  varying  from  a  pinhead 
to  hemp-seed  in  size.  Her  liver  was  enlarged;  the  surface 
smooth.  The  urine  contained  six  per  cent,  of  sugar  and  bile 
pigment.  The  lesions  had  remained  unchanged  during  six 
months'  observation. 

PROF.  ERICH  HOFFMANN,  of  Berlin,  said  the  localization  and 
appearance  of  the  lesions  in  this  case  were  suggestive  of  diabetes. 

DR.  JOSEPH  ZEISLER,  of  Chicago,  said  he  did  not  think  it  was 
at  all  characteristic  of  diabetes  to  find  these  tuberose  forms  of 
the  eruption.  It  was  the  generalized  form  of  xanthoma  that  was 
more  commonly  observed  in  diabetes. 

DR.  A.  R.  ROBINSON,  of  New  York,  said  he  was  inclined  to  agree 
with  Dr.  Zeisler  that  the  tuberose  form  of  xanthoma  with  such  a 
localization  as  was  shown  in  Dr.  Fox's  case  was  not  met  with  in 
diabetes.  In  connection  with  that  disease,  the  eruption  was  apt 
to  be  more  generalized  and  the  lesions  variously  sized  with  fre- 
quently a  hyperaemic  periphery. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  he  agreed  with  the 
general  statement  that  xanthoma  diabeticorum  did  not,  as  a  rule, 
show  the  nodular  lesions  observed  in  Dr.  Fox's  case.  Still,  there 
was  no  hard  and  fast  rule,  and  the  speaker  said  he  recalled  a  case 
where  he  had  made  a  diagnosis  of  diabetes  from  the  appearance 


DERMATOLOGICAL  CONGRESS  449 

of  lesions  of  this  kind  on  the  buttocks.     He  had  seen  very  extensive 
cases  of  xanthoma  with  sugar  and  without  sugar. 

DR.  FRANCIS  J.  SHEPHERD,  of  Montreal,  said  that  at  a  meeting 
of  the  American  Dermatological  Association  held  in  Montreal 
some  years  ago  he  reported  a  case  of  xanthoma  associated  with 
diabetes  and  gall  stones.  After  the  removal  of  the  gall  stones, 
the  xanthoma  disappeared.  The  glycosuria  in  this  case  was 
probably  due  to  some  involvement  of  the  pancreas  and  the 
xanthoma  due  to  some  liver  condition. 

DR.  J.  NEVINS  HYDE,  of  Chicago,  said  that  almost  all  of  the  in- 
stances of  xanthoma  diabeticorum  that  he  had  observed  were  cases 
of  glycosuria  and  not  diabetes,  and  the  sugar  had  disappeared 
coincidently  with  the  xanthoma. 

DR.  JOSEPH  GRINDON,  of  St.  Louis,  said  the  case  shown  by  Dr. 
Fox  looked  like  the  tuberose  form  of  xanthoma,  and  that  the 
eruption  was  not  characteristic  of  xanthoma  diabeticorum  as  he 
knew  it. 

A  Case  of  Naevus  Pigmentosus  Removed  with  Liquid  Air 
PRESENTED  BY  DR.  WILLIAM  B.  TRIMBLE  OF  NEW  YORK 
The  patient  was  a  girl  aged  twenty.     The  lesion,  about 
three  quarters  of  an  inch  in  diameter,  had  been  situated  to 
the  left  of  the  middle  line  of  the  chin  just  below  the  angle 
of  the  mouth.     It  was  of  the  mouse  skin  variety,  a  peculiar 
feature   being  that  the   central   portion   was   verrucous  and 
elevated  about  one-eighth  of  an  inch  above  the  surface.     Four 
treatments  with  liquid  air  had  effected  a  cure;  the  pigmenta- 
tion had  disappeared  and  no  noticeable  scar  was  left. 

A  Case  of  Acne  Necrotica 
PRESENTED  BY  DR.  GEORGE  HENRY  Fox,  OF  NEW  YORK 

Woman,  ast.  twenty-two;  single;  Russian;  dressmaker. 
Family  history  negative. 

Patient  had  always  been  rather  delicate.  She  suffered 
from  "colds"  rather  often;  never  noticed  any  glandular  en- 
largements. She  expectorated  blood  on  one  occasion.  She 
did  not  sweat  at  night;  lost  ten  pounds  last  year.  Lesions 
on  her  ankles  appeared  three  and  one-half  years  ago.  One 
and  one-half  years  ago  lesions  appeared  on  backs  of  hands  and 
several  weeks  later  on  posterior  surface  of  forearms,  elbows, 

VOL.   I.— a 9 


450  SIXTH  INTERNATIONAL 

and  lower  parts  of  arms.  Three  months  later  others  were 
noted  on  the  buttocks  and  back  of  thighs.  The  pigmented 
patch  on  the  face  had  existed  five  years. 

Examination  showed  patient  to  be  fairly  well  nourished. 
There  were  extensive  patches  of  chloasma  on  the  forehead  and 
cheeks.  On  the  backs  of  hands,  they  were  more  or  less  grouped 
over  the  knuckles.  On  the  backs  of  forearms,  elbows,  and  lower 
half  of  arms,  on  buttocks,  backs  of  calves,  and  dorsa  of  feet 
were  numerous  discrete  lesions  as  follows :  pinhead  to  pea-sized 
maculo-papules  and  papules  of  a  purplish  tint,  some  of  the 
papules  showing  minute  central  crusts .  No  vesicles  were  present . 
Scattered  among  the  lesions  were  pinhead  to  pea-sized  pitted 
scars,  some  white,  others  bluish  in  color.  Face,  trunk,  palms, 
and  soles  were  free  of  lesions. 

DR.  JOSEPH  ZEISLER,  of  Chicago,  said  he  thought  the  case  shown 
by  Dr.  Fox  was  extremely  interesting.  One  of  the  members  had 
suggested  the  diagnosis  of  lichen  planus,  but  that  could  be  readily 
disposed  of  on  account  of  the  peculiar  location  of  the  lesions  about 
the  elbows.  The  speaker  said  he  regarded  the  eruption  as  coming 
under  the  category  of  what  the  French  had  termed  folliclis.  There 
were  a  number  of  scars  present,  which  showed  that  there  was  an 
atrophic  process  going  on. 

A  Case  of  Adenoma  Sebaceum 
PRESENTED  BY  DR.  GEORGE  HENRY  Fox,  OF  NEW  YORK 

Girl,  aet.  nineteen;  single,  U.  S. 

Present  eruption  began  at  five  years  of  age  as  small  solid 
colorless  elevations  which  became  reddened  two  years  later. 
Since  then  there  had  been  no  change  in  the  eruption.  The 
lesions  consisted  of  pinhead  to  hemp-seed-sized,  firm,  reddish, 
discrete  nodules,  seen  in  greatest  abundance  about  the  nose, 
cheeks,  and  forehead.  The  patient's  intellect  was  considerably 
below  the  average.  She  had  three  sisters  all  of  whom  were 
very  bright  and  who  had  fine  complexions.  Treatment  of 
the  left  side  of  the  face  by  electrolysis  had  produced  consider- 
able improvement. 

That  the  term  "adenoma  sebaceum"  was  in  many  cases 
a  misnomer  was  seen  from  the  pathological  report  of  this  case 
by  Dr.  A.  M.  Pappenheimer  who  said:  "Histologically  the 


DERMATOLOGICAL  CONGRESS  451 

tumors  seem  like  multiple  small  fibromata,  which  in  places 
have  a  papillomatous  contour.  The  presence  of  a  few  se- 
baceous glands  in  the  nodule  excised  from  the  nose  where 
they  are  normally  so  abundant  would  not  I  think  justify 
one  in  calling  it  an  adenoma  sebaceum.  None  of  the  nodules 
are  very  vascular,  certainly  not  sufficiently  so  to  warrant  their 
classification  with  the  angiomata. " 

A  Case  of  Sclerodactylia  Associated  with  Raynaud's  Disease 
PRESENTED  BY  DR.  HOWARD  Fox,  OF  NEW  YORK 

JEt.  fifty;  widow;  Sweden;  cook. 

When  twenty- four  years  old  her  hands  were  frost  bitten. 
Ten  years  later  she  began  to  suffer  from  "dead  fingers"  in  all 
of  the  terminal  phalanges.  These  attacks  were  brought  on 
by  exposure  to  cold.  Twenty-one  years  ago  "blood  blisters" 
began  to  appear  on  the  tips  of  fingers  and  some  of  the  toes. 
Some  of  these  developed  into  deep-seated  sores  on  the  finger 
ends,  exposing  the  bone.  Ten  years  ago,  fingers  began  to  be 
stiff  and  the  overlying  skin  drawn  and  tight.  Five  years  ago 
there  were  sudden  paroxysmal  attacks  of  blindness,  which 
would  appear  at  intervals  of  two  weeks  and  last  a  few  minutes. 
Attacks  continued  for  a  year  and  then  ceased.  She  lost 
forty  pounds  since  the  beginning  of  her  illness. 

Examination  showed  skin  of  thumbs  and  fingers  to  be 
smooth,  glossy,  and  tightly  stretched.  After  exposure  to 
cold,  alternating  pallor  and  blueness  were  noted  in  terminal 
and  second  phalanges.  Some  of  the  terminal  phalanges  were 
absent,  others  greatly  atrophied.  There  was  considerable 
autolysis  of  the  joints  of  her  right  hand.  A  radiograph  of 
the  left  hand  showed  marked  bone  atrophy.  The  skin  over 
arms,  face,  and  shoulders  was  tight  and  drawn. 

(Case  reported  in  Jour.  Cutan.  Dis.,  August,   1907.) 

A  Case  of  Slowly  Spreading  Pigmentation  over  the  Left  Scapula  and  Clavicle 

PRESENTED  BY  DR.  A.  R.  ROBINSON,  OF  NEW  YORK 
The   pigment   formed  larger  and   smaller  patches.     The 
color  was  like  that  in  tinea  versicolor,  but  there  was  no  scaling. 
Hypertrichosis  was  present  in  the  oldest  part,  bearing  some 
resemblance  to  naevus. 


452  SIXTH  INTERNATIONAL 

Microscopically,  sections  showed  hyperpigmentation,  as 
in  chloasma. 

A  Case  of  Extensive  Lupus,  Involving  both  Groins,  the  Entire  Lower  Ab- 
dominal Region,  the  Sheath  of  the  Penis  and  Glans  Penis;  Cured  by 

Curettage  and  the  Thermo -Cautery 

PRESENTED  BY  DR.  PRINCE  A.  MORROW,  OF  NEW  YORK 
The  patient  was  fifty-five  years  of  age.  About  fifteen 
years  ago  his  left  testicle  was  removed  for  tuberculosis.  Soon 
thereafter  he  was  under  the  demonstrator's  observation  at 
the  New  York  Hospital  for  a  short  time,  as  the  disease  had 
spread  to  the  adjacent  inguinal  region.  He  soon  disappeared 
and  did  not  come  under  observation  again  until  November, 
1905.  At  that  time  the  eruption  had  extended  over  the 
entire  lower  abdominal  surface,  involving  the  umbilicus, 
with  numerous  tuberculous  nodules  and  ulcerations  of  the 
skin  of  the  penis. 

He  was  anaesthetized  and  the  entire  affected  surface 
was  thoroughly  curetted — followed  by  the  Paquelin  cautery. 
Occasional  repetition  of  the  curettage  when  nodules  reap- 
peared, was  followed  by  a  complete  cure  in  three  months. 

The  patient  presented  himself  again  in  1906  with  a  new 
development  of  deep  ulcerative  lesions  upon  the  glans  penis, 
which  were  curetted  and  cauterized.  At  that  time  it  was 
found  that  he  had  two  tight  strictures  of  the  penile  portion  of 
the  urethra,  which  were  divided.  He  was  discharged  ap- 
parently well,  with  directions  to  keep  them  open  by  the  daily 
use  of  a  bougie. 

He  returned  the  week  before  presentation  with  partial 
retention  of  urine  from  recontraction  of  the  strictures.  It  was 
possible  that  the  urethra  is  involved  in  the  tuberculous  process. 
One  feature  of  interest  in  the  case  was  that  a  tuberculous 
process,  having  its  primary  focus  in  the  testicle,  instead  of 
following  the  course  of  the  cord,  was  deviated  to  the  con- 
tiguous cutaneous  surface. 

A  Case  of  Dermatitis  Herpetiformis 

PRESENTED  BY  DR.  WILLIAM  B.  TRIMBLE,  OF  NEW  YORK 
Patient  was  a  man  aged  forty-four;  native  of  Ireland. 
There  had  been  no  tuberculosis  in  the  family.  The  pa- 


DERMATOLOGICAL  CONGRESS  453 

tient  had  had  an  attack  of  pneumonia  in  1888  and  was  at 
the  present  time  tuberculous.  His  skin  eruption  was  papulo- 
vesicular,  grouped  and  generalized  and  of  eighteen  years' 
duration.  It  occurred  in  exacerbations,  about  one  attack 
a  year,  the  disease  never  entirely  disappearing. 

A  Case  of  Carcinoma   of  the  Caecum,  Treated  by  Extra -Abdominal  X-Ray 

Exposures,  Apparently  Cured 

PRESENTED  BY  DR.  CARL  BECK,  OF  NEW  YORK 
Patient,  a  man  of  sixty-five  years,  recently  developed 
signs  of  cachexia,  obstruction,  and  tenderness  in  the  right 
iliac  region.  On  April  14th  a  hard  mass  the  size  of  an  out- 
stretched hand  was  felt  in  that  region.  An  opening  of  the 
abdomen  was  made  above  the  tumor  which  was  firmly  ad- 
herent to  the  posterior  region  of  the  fossa.  It  was  hard, 
with  irregular  surface  and  the  typical  appearance  of  a  fibrous 
carcinoma.  Its  anterior  surface  was  stitched  to  the  peri- 
toneum so  that  a  portion  of  the  extent  of  the  palm  of  a  man's 
hand  was  exposed.  One  day  after  the  operation  a  five- 
minute  X-ray  exposure  with  tubular  diaphragm  of  the  reporter 
was  made.  This  was  repeated  seven  days  in  succession, 
with  a  strong  current,  then  every  second  day.  Two  weeks 
after  the  first  irradiation  there  was  a  slight  erythema.  There 
was  an  interval  of  two  weeks'  rest  and  then  exposure  twice  a 
week.  Five  weeks  after  the  operation  the  tumor  could  not 
be  palpated.  At  the  time  of  presentation,  five  months  after 
the  operation,  the  patient  was  well.  There  were  no  signs 
of  swelling. 


THE  REGULAR  SESSION  OF  THE  CONGRESS  WAS  CALLED  TO  ORDER 

AT  ii  A.M. 

PROF.  E.  GAUCHER,  of  Paris,  and  DR.  ANDREW  R.  ROBIN- 
SON, of  New  York,  Vice-Presidents,  in  the  Chair. 


WEITERE    ERFAHRUNGEN    MIT    DEM    WEISS- 
UND     BLAULICHT     DER     QUARZLAMPE 

VON  PROF.  ERNST  KROMAYER,  BERLIN 

VORBEMERKUNG 

Durch  Finsen's  epochemachendes  Lebenswerk  ist  das 
Licht  ein  Heilmittel  ersten  Ranges  geworden.  Seiner 
allgemeinen  Verbreitung  stand  aber  der  hohe  Preis  und  die 
Schwerfalligkeit  der  Finsenapparate  entgegen. 

In  der  medizinischen  Quarzlampe  glaube  ich  einen  Ersatz 
der  Finsen-apparate  und  eine  bequeme  Lichtquelle  angegeben 
zu  haben,  sodass  nunmehr  die  Lichtbehandlung  Allgemeingut 
der  Arzte  werden  kann. 

Die  Quarzlampe  ist  eine  aus  geschmolzenem  Quarzglas 
bestehende  Quecksilber-Vakuumlampe,  die  in  ein  fliessendes 
Wasserbad  eingebettet  ist,  dessen  Gehause  in  Grosse  e.  Faust 
das  Licht  durch  ein  Quarzfenster  austreten  lasst,  das,  wie 
Finsen'sche  Drucklinse  direkt  als  Compressorium  benutzt 
werden  kann. 

Seit  meiner  ersten  Veroffentlichung  uber  die  Quarzlampe 
(i)  sind  bereits  eine  ganze  Reihe  von  Arbeiten  erschienen,  die 
meine  Angaben  zwar  zum  grossen  Teil  bestatigen,  aber  gleich- 
zeitig  eine  Reihe  berechtigter  Ausstellungen  machen.  Es  sei 
mir  gestattet,  diese  gemeinsam  mit  meinen  eigenen  weiteren 
Erfahrungen  und  den  inzwischen  gemachten  Verbesserungen 
an  der  Lampe  hier  zu  besprechen. 

454 


SIXTH  INTERNAT.  DERMATOL.  CONGRESS        455 
i .  Oberfldchenwirkung  der  Quarzlampe 

Die  grosse  tiberlegene  Flachenwirkung  der  Quarzlampe 
wird  allseitig  auch  vom  Finseninstitut  in  Kopenhagen  aner- 
kannt  (4,  5).  Einigen  Autoren  [Busk  (4),  Stern  (10)  ]  erscheint 
sie  aber  zu  gross  zu  sein  und  leicht  zu  unliebsamenLichtnekrosen 
Veranlassung  geben  zu  konnen.  Obgleich  ich  nur  in  zwei 
Fallen  nach  einstundiger  Belichtung  Lichtnekrosen  habe 
auftreten  sehen,  so  erscheint  mir  doch  die  starke  Oberflachen- 
wirkung  der  Quarzlampe  in  den  Fallen  unerwiinscht  zu  sein, 
wo  eine  Tiefenwirkung,  wie  beim  Lupus,  beabsichtigt  ist. 

Durch  Beimengung  einer  Methylenblaulosung  (u,  14,  i4a) 
zur  Spiilflussigkeit  der  Lampe  kann  diesem  Ubelstande 
abgeholfen  werden,  indem,  wie  ich  schon  fruher  gezeigt  habe, 
ein  grosser  Teil  der  ausseren  ultra violetten  Strahlen,  auf  denen 
die  Oberflachenwirkung  beruht,  ebenso  absorbiert  wird, 
wie  ein  Teil  der  Warmestrahlen,  sodass  das  "blaue"  Queck- 
silberlicht  eine  Auslese  derjenigen  Strahlen  enthalt,  denen 
neben  einer  grossen  photochemischen  Wirksamkeit  die  relativ 
grosste  Penetrationsfahigkeit  zukommt. 

Eine  gleiche  Auslese  der  Strahlen  kann  durch  Filtrirung 
des  Lichtes  durch  eine  blaue  "  Ultra violett "  Glasscheibe,  wie 
sie  die  Quarzlampen-Gesellschaft  an  den  spater  zu  besprechen- 
den  abnehmbaren  "  Belichtungsansatzen "  angebracht  hat, 
erreicht  werden  (i4b). 

Bering  (6)  hat  experimentell  nachgewiesen,  dass  das  blaue 
Quecksilberlicht  dem  weissen  in  seiner  Tiefenwirkung  quanti- 
tativ  nicht  nachsteht,  sodass  es  also  vorteilhaft  uberall  dort 
angewendet  werden  kann,  wo  eine  Tiefenwirkung  des  Lichtes 
beabsichtigt  ist. 

Ueberall  aber,  wo  es  nur  auf  Erzeugung  einer  oberflach- 
lichen  Hautentzundung  ankommt,  ist  natiirlich  das  weisse 
Quecksilberlicht  anzuwenden,  das  nach  Busk  (4)  schon  nach 
Einwirkung  von  i  Sekunde  ein  deutliches  Lichterythem  am 
Vorderarm  hervorruft. 

2.   Tiefenwirkung  der  Quarzlampe 
Wahrend  ich  nach  meinen  experimentellen  und  klinischen 


456 


SIXTH  INTERNATIONAL 


Erfahrungen  eine  grossere  Tiefenwirkung  meiner  Lampen  als 
der  Finsenapparate  annehmen  zu  konnen  glaubte,  habe  ich 
in  diesem  Ptmkte,  wenn  auch  Zustimmung,  so  doch  mehr 
Widerspruch  erfahren,  Zustimmung  von  Wetterer  (3),  Lohde 
(13)  auf  Grund  klinischer  Erfahrung  von  Wichmann  (9)  und 
besonders  von  Bering  (6)  auf  Grund  experimenteller  Unter- 
suchung,  Widerspruch  von  Schultz  (12),  Stern  und  Hesse  (10) 
Busk  (4),  Johannsen  (5)  auf  Grund  theoretischer  Uberlegung 
und  experimenteller  Untersuchung. 

Die  entgegengesetzten  Resultate  der  verschiedenen  Forscher 
scheinen  mir  auf  einer  differenten  Anordnung  der  betreffenden 
Experimente,  einer  verschiedenen  Handhabung  der  Lampen 
und  einem  ungleichen  Calcul  zu  beruhen,  was  am  deutlichsten 
aus  der  Arbeit  von  Johannsen  (5)  (Finseninstitut  zu  Kopen- 
hagen)  hervorgeht.  Johannsen  gibt  fur  die  Lichtenergie  beider 
Lichtquellen  folgende  Tabelle: 


Sichtbare 
Strahlen 
(bis  0,4) 

Innere  ultra- 
violette  Strahlen 
(o,  4  bis  0,32) 

Aussere   ultra- 
violette  Strahlen 
(von  0,32) 

Finsen-Reyn  Lampe 

4,4 

7,i 

16 

Prof.    Kromayers 
Quecksilber  Lampe 

2,0 

8,0 

ca.  35 

Da  die  sichtbaren  Strahlen  (bis  0,4)  die  penetrations- 
fahigsten  sind,  vindiciert  er  der  Finsenlampe  die  starkere 
Tiefenwirkung  (4,4:  2,0),  wahrend  er  der  Quarzlampe  die 
starkere  Oberflachenwirkung  zuspricht  (35:  16). 

Johannsen  hat  hierbei  die  Lichtenergie  der  Finsenlampe 
im  Finsen-Reyn  Fleck  (2,1  cm.  Diameter)  gemessen,  d.  h.  an 
der  Stelle,  an  der  die  Lichtstrahlen  die  grosste  Centrirung  haben, 
wahrend  die  therapeutisch  ausgenutzte  Lichtenergie  der  Fin- 
senapparate sich  gleichmassig  auf  die  Flache  der  Finsen'schen 
Drucklinse  verteilt,  die  einen  Durchmesser  von  ca.  3,5  cm. 
hat.  Die  therapeutisch  ausgenutzte  Lichtenergie  der  Finsen- 
apparate verhalt  sich  also  (naturlich  auf  gleiche  Flacheneinheit 
bezogen)  zu  der  von  Johannsen  im  Finsen-Reyn  Fleck  gemesse- 


DERMATOLOGICAL  CONGRESS  457 

nen  umgekehrt  wie  das  Quadrat  von  3,5  zu  dem  von  2,1  oder 
wie  441  zu  1225  oder  fast  wie  i :  3. 

Um  die  therapeutisch  ausgenutzte  Lichtenergie  beider 
Lampen  zu  vergleichen,  sind  also  die  von  Johannsen  angegebe- 
nen  Zahlen  fur  die  Finsen-Reyn  Lampe  durch  3  zu  dividieren, 
wodurch  alsdann  die  starke  therapeutische  Uberlegenheit 
der  Quarzlampe  iiber  die  Finsen-Reyn  Lampe  in  alien  Strahlen- 
gattungen  klar  zu  Tage  tritt,  und  zwar  nach  den  im  Finsen- 
institut  in  Kopenhagen  selbst  gemachten  Lichtmessungen : 

fur  die  sichtbaren  Strahlen  (bis  0,4)  wie  2:1,  s(ca.) 

"  "  inneren  ultraviolet- 
ten  Strahlen  (bis  0,32)  wie  8:  2,4  (ca.) 

"  "  ausseren  ultravio- 

letten  Strahlen  (von  0,32  an)  wie  35:  5,6  (ca.) 

Bering  (6)  hat  die  Durchdringungsfahigkeit  des  Lichtes 
beider  Lampen  durch  Mausehaute  mit  dem  Eder'schen  Photo- 
meter (Trubung  einer  Losung  von  neutralem  Ammoniumoxalat 
und  Quecksilberchlorid  durch  Lichtwirkung)  verglichen  und 
macht  folgende  Angaben : 

Finsen-Reyn  Lampe :     Eine  Haut  nach  3  Min.  Trubung 

Zwei  Haute  nach  15  Min.  schwache  Trubung 
Drei  Haute  keine  Trubung 

Quarzlampe:     Eine  Haut  nach  15  Sec.  Trubung 
Zwei  Haute  nach  30  Sec.  Trubung 
Drei  Haute  nach  i£  Min.  Trubung 

Darnach  ware  die  Tiefenwirkung  der  Quarzlampe  wenig- 
stens  3omal  starker  als  die  der  Finsen-Reyn  Lampe. 

Wichmann  (9)  halt  die  Tiefenwirkung  des  Blaulichtes  der 
Quarzlampe  fur  grosser  als  die  der  Finsen-Reyn  Lampe,  die  des 
Weisslichtes  hingegen  fur  geringer,  da  durch  die  grosse  Masse 
der  ausseren  ultravioletten  Strahlen  dieses  Lichtes  bei  langerer 
Bestrahlungsdauer  Veranderungen  in  den  oberflachlichen 
Hautschichten  hervorgerufen  wiirden,  welche  dem  Durchgang 
der  Strahlen  in  die  Tiefe  hinderlich  seien. 

Ich  selbst  habe  die  Tiefenwirkung  der  Quarz-  und  Finsen- 
Reyn  Lampe  noch  jungst  wieder  an  meinen  eigenen  Vorderar- 
men  durch  Zwischenlage  gut  angefeuchteter  Papierlagen 
gepriift  und  folgende  Resultate  gehabt : 


458 


SIXTH  INTERNATIONAL 


i  PAPIERLAGE 

2  PAPIERLAGEN 

3  PAPIERLAGEN 

Dauer 
der  Be- 

strah- 
lung 

Reak- 
tion 

Dauer 
der  Be- 
strah- 
lung 

Reak- 
tion 

Dauer 
der  Be- 

strah- 
lung 

Reak- 
tion 

Quarzlampe 
(Weisslicht) 

5  Min. 

heftige 
Entzun- 
dung 

5  Min. 

keine 

30  Min. 

keine 

10  Min. 

massige 
Entziin- 
dung 

50  Min. 

fsringe 
ntziin- 
dung 

Finsen- 
Reyn  Lampe 

5  Min. 

leichte 
Rotung 

5  Min. 
10  Min. 

keine 
keine 

30  Min. 
50  Min. 

keine 
keine 

Die  Finsen-Reyn  Lampe  brannte  mit  21  Amp.,  der  Licht- 
bogen  war  5,5  cm.  von  der  hinteren  Quarzscheibe  des  Concen- 
tration sapparates  entfemt.  Als  Quarzlampe  benutzte  ich  das 
kaufliche  Modell  mit  nicht  regulierbarem  Widerstande. 

Das  letzte  und  entscheidende  Wort  iiber  den  Wert  der 
so  viel  diskutierten  "Tiefenwirkung"  wird  aber  erst  die 
therapeutische  Erfahrung  zu  sprechen  haben. 

3.     Behandlung  schwer  zuganglicher  Hautstellen  und  der 

Schleimhdute 

Mit  Recht  wird  von  den  meisten  Autoren  betont,  dass  das 
4,5  cm.  im  Durchmesser  grosse,  plane  Quarzfenster  der  im 
Handel  befindlichen  Lampe  ungeeignet  sei,  um  schwerer 
zugangliche  Hautstellen  (Augenwinkel,  Nasenpartien  etc.) 
durch  Compression  zu  behandeln.  Dieser  Ubelstand  ist 
jetzt  durch  verschieden  gestaltete  kleinere  Compressorien  1 
beseitigt,  die  dem  Quarzfenster  adaptirt  werden.  Die  Licht- 
energie  wird  nach  meinen  Berechnungen  und  Beobachtungen 
durch  diese  Ansatze  nur  unwesentlich  verringert.  Auf  Anre- 
gung  von  Schuler  (8,  8a)  hat  die  Quarzlampengesellschaft 
solide  Quarzglasstabe  hergestellt  zur  Behandlung  kleinerer 
Hautstellen  und  der  Schleimhaute  (i4b). 

In  diesen  Quarzstaben,  deren  eines  Ende  direkt  auf  das 
plane  Fenster  der  Quarzlampe  aufgesetzt  wird,  pflanzt  sich  das 

1  Von  der  Quarzlampen-Gesellschaft  Berlin-Pankow  hergestellt  und  ver- 
trieben  (i4b). 


DERMATOLOGICAL  CONGRESS  459 

Licht  durch  totale  Reflexion  fort,  um  am  Ende  des  Stabes  in 
voller  Intensitat  auszutreten.  Mit  ihnen  ist  es  moglich,  die 
Schleimhaute  der  Harnrohre,  des  Mundes,  des  Rachens,  der 
Nase,  ja  voraussichtlich  auch  der  Harnblase  und  des  Kehlkopfes 
phototherapeutisch  zu  behandeln. 

4.     Indikationen  und  therapeutische  Resultate 

Das  Quarzlampenlicht  ist  bisher  erfolgreich  angewandt 
worden  bei  folgenden  Krankheiten:  Lupus  vulgaris,  Lupus 
erythematodes,  Cancroid,  Teleangiectasia,  Naevus  vasculosus, 
Acne  rosacea,  Acne  vulgaris,  Furunculosis,  Folliculitis  barbae, 
Folliculitis  decalvans  capitis,  Eczem,  Psoriasis,  Alopecia  pity- 
rodes,  Alopecia  areata,  Ulcera  cruris  [Kromayer  (2),  Wetterer 
(3),  Muller  (7),  Wichmann  (9),  Stern-Hesse  (10),  Lohde  (13)]. 

Unter  diesen  Krankheiten  beanspruchen  das  Hauptinter- 
esse  der  Lupus  vulgaris,  die  Teleangiectasien  (Naevus  vascu- 
losus) und  die  Alopecia  areata,  weil  bei  diesen  Krankheiten  das 
Licht  Heilung  zu  bringen  vermag  uber  alle  anderen  bisherigen 
Mittel  hinaus. 

Wahrend  ausser  mir  noch  Lohde  (13),  Wichmann  (9), 
Muller  (7),  Wetterer  (3)  die  Quarzlampe  den  Finsenapparaten 
fur  die  Lupusbehandlung  vorziehen  und  insbesondere  Wetterer 
mit  der  Quarzlampe  noch  Heilungsresultate  erzielt  hat  in 
Fallen,  wo  Finsen-Reyn  versagt  hatte,  sind  Stern-Hesse  von 
der  Wirkung  der  Quarzlampe  nicht  befriedigt,  allerdings  haben 
diese  Autoren  die  Belichtungszeit  zu  kurz  gewahlt  (10  Min.). 

Fur  die  Behandlung  der  Teleangiectasien  (Naevus  vasculo- 
sus), (Acne  rosacea)  steht  das  Quarzlampenlicht  nach  Muller 
(7)  an  erster  Stelle.  Jedenfalls  lassen  sich  ausgedehnte  Gefass- 
male  nur  durch  die  Quarzlampe  beseitigen  oder  bessern. 

Bei  der  Alopecia  areata,  soweit  sie  uberhaupt  heilbar  ist 
und  nicht  durch  Recidive  eine  Heilung  illusorisch  macht, 
ist  die  Lichtentziindung  anerkanntermassen  das  sicherste 
Heilmittel,  das  in  der  Quarzlampe  in  bequemster  Form  geboten 
wird,  ohne  dass  naturlich  dieses  Licht  in  der  Heilwirkung  vor 
anderen  Licht quellen  etwas  voraus  hat. 

Bei  den  ubrigen  oben  angefuhrten  Krankheiten  kann  zwar 
das  Licht  in  einzelnen  Fallen  von  vorzuglicher  und  vielleicht 
unersetzlicher  Wirkung  sein,  es  ist  aber  dabei  zu  bedenken, 


460  SIXTH  INTERNATIONAL 

dass  wir  fur   das  Gros   der   Falle   bequemere   Behandlungs- 
methoden  haben. 

5 .     Schlussbemerkung 

Wir  stehen  meiner  Ansicht  nach  zur  Zeit  noch  im  ersten 
Beginn  der  Lichtbehandlung.  Erst  jetzt,  nachdem  eine  be- 
queme,  billige  und  wirksame  Lichtquelle  gefunden  ist  und 
nachdem  auch  die  Schleimhaute  der  Lichttherapie  zugangig 
gemacht  worden  sind,  kann  die  Lichtbehandlung  Gemeingut 
aller  A'rzte  werden,  die  alsdann  viribus  unitis  die  Indication  en 
der  Lichtbehandlung  erweitern  und  ihre  Grenzen  festzustellen 
imstande  sind. 

LITTERATUR 

1.  KROMAYER,  "  Quecksilberwasserfampen  zur  Behandlung  von  Haut  und 
Schleimhaut."     Deutsche  med.  Wochenschr.,  1906,  No.  10. 

2.  KROMAYER,  "Die  Anwendung  des  Lichtes  in  der  Dermatologie."     Ber- 
liner klin.  Wochenschr.,  1907,  No.  3. 

3.  WETTERER,  "Ubereinige  Erfahrungen  mit  der  Kromayer'schen  Quarz- 
lampe."     Arztliche  Mitteilungen  aus  und  fur  Baden,  1907,  No.  7  und  Arch, 
f.  physik.  Medicin  u.  med.  Technik.    Leipzig,  Band  II.,  Heft,  3-4. 

4.  GUANI    BUSK,   "  Bemerkungen  uber  die    Kromayer'sche  Quecksilber- 
wasserlampe  "  (aus  Finsens  medicinischem  Lichtinstitut  Kopenhagen).  Ber- 
liner klin.  Wochenschr.,  1907,  No.  28. 

5.  E.  S.  JOHANNSEN,  " Untersuchungen  iiber  die  Wirkung  der  Kromayer- 
Lampe  und  der  Finsen-Reyn  Lampe  auf  Chlorsilberpapier  "   (aus  Finsens 
medicinischem  Lichtinstitut,  Kopenhagen).    Berlinerlklin.  Wochenschr.,  1907, 
No.  31. 

6.  BERING,  "  Uber  die  Wirkung  violetter  undultravioletter  Lichtstrahlen." 
Mediz.     Naturwissensch.  Archiv.    Berlin,    1907,    No.   i.     (Aus  der  Konigl. 
Universitats-Klinik  fur  Hautkrankh.  Kiel.) 

7.  G.  J.  MULLER,  "Uber  den  derzeitigen  Stand  und  die  Aussichten  der 
Aktinotherapie."     Deutsche  med.  Wochenschr.,  1907,  No.  33. 

8.  SCHULER,  "Neue   Bergkristallansatze    fur    die    Lichtbehandlung    von 
Schleimhauten."     Deutsche  med.  Wochenschr.,  1907,  No.  12. 

SA.  SCHULER  "  Demonstrationen  einiger  Modifikationen  zur  Quecksilber- 
quarzlampe."     Dermal.  Zeitschr.,  1907,  S.  367. 

9.  WICHMANN     (Aus   der  Lupusheilanstalt   fur   Kranke   der  Landesver- 
sicherungsanstalt  der  Hansastadte  zu  Hamburg),  " Experimentelle  Unter- 
suchungen uber  die  biologische  Tiefenwirkung  des  Lichtes  der  medizinischen 
Quarzlampe  und  des  Finsenapparates." 

10.  STERN    UND  HESSE,  "Experimentelle  und  klinische   Untersuchungen 
des  ultravioletten  Lichtes  (Quarzlampenlicht)."     Dermat.  Zeitschr.,  1907  S., 
469. 

11.  KROMAYER,  "Das  neueste  Modell  der  Quarzlampe  mit  Nebenappa- 
raten."     Dermat.  Zeitschr.,  1907  S.,  235. 

12.  SCHULTZ,  "Zur  Frage  der  Tiefenwirkung  des  ultravioletten  Lichtes." 
Dermat.  Zeitschr.,  1907  S.,  369. 


DERMATOLOGICAL  CONGRESS  461 

13.  LOHDE,  "  Kromayer'sche  Quarzlampe."     Deutsche  med.  Wochenschr., 
1907,  S.,  1278. 

14.  "Die  Medizinische  Quarzlampe  nach  Prof.  Kromayer."     Prospekt  der 
Quarzlampen-Gesellschaft  Berlin-Pankow,  1907. 

i4A.  "Blaulicht  nach  Prof.  Kromayer."  Prospekt  der  Quarzlampen-Ges. 
Berlin-Pankow,  1907. 

143.  "Die  Lichtbehandlung  der  Schleimhaute.  Compressorien  fur  die 
mediz.  Quarzlampe  fur  die  Lichtbehandlung  kleinerer  Hautstellen.  Blau- 
lichtfilter  aus  Ultraviolet!  und  Quarzglas."  Prospekt  der  Quarzlampen-Ges., 
1907. 


THE     SPECIFIC     ACTION     OF     RADIUM     AS     A 
UNIQUE  FORCE  IN  THERAPEUTICS 

BY  DR.  ROBERT  ABBE,  OF  NEW  YORK 

In  recounting  the  diseased  conditions  of  the  body  in  which 
we  see  favorable  restorative  power  from  radium,  I  do  not 
invite  criticism  from  those  who  may  say  that  the  same  effects 
can  be  produced  by  caustics,  Roentgen  rays,  dietetics,  local 
medication,  or  electricity.  I  wish  briefly  to  present  facts  to 
show  that  radium  acts  entirely  unlike  these,  and  to  clear  the 
air  of  some  prevailing  exaggeration  and  doubts. 

Butlin  recently  said  "there  are  two  kinds  of  evidence: 
that  which  satisfies  the  inquirer  who  wishes  to  believe,  and 
that  which  is  required  by  the  skeptic."  If  both  these  could 
follow  the  interesting  series  of  results  which  men  who  have 
been  able  to  use  this  remedy  have  seen,  argument  would  be 
simple. 

The  inefficiency  of  word  description  or  photography  in 
delineating  surgical  growths,  led  me  long  since  to  keep  records 
by  plaster-of-paris  casts,  where  possible,  to  enable  me  more 
accurately  to  compare  by  measurement  and  appearance  before 
and  during  the  study  of  radium  effects. 

A  few  demonstrations  of  this  are  more  quickly  convincing 
than  words  or  photographs.  As  a  basis  for  argument,  there- 
fore, I  present  to  your  notice  a  small  group  of  casts  chosen 
from  hundreds  which  I  have  made. 

As  a  typical  epithelial  carcinoma,  observe  this  round, 
raised  growth  on  one  side  of  the  forehead.  It  is  2  cm.  in 
diameter  by  a  half  cm.  in  height.  Strong  radium  (60  mgr. 


462  SIXTH  INTERNATIONAL 

pure  radium  bromide)  sealed  in  a  glass  tube,  pressed  against 
the  growth  for  one  hour,  produced  a  prompt  disappearance 
with  only  a  shallow  pink  cicatrix. 

Another  of  the  same  size  on  one  side  of  the  nose  growing 
worse  for  two  years,  in  an  elderly  lady,  and  showing  fungus 
ulceration,  disappeared  in  four  weeks  after  one  application 
of  one  hour.  The  accompanying  cast  shows  the  almost  in- 
visible shallow  cicatrix.  This  has  remained  cured  for  three 
years.  Scores  of  such  cases  have  yielded  similar  results 
under  radium  treatment.  Many  of  these  casts  have  been 
modelled  before  and  after  treatment  and  show  the  specific 
action  of  this  agent,  with  almost  infallible  results. 

Observe  this  severe  case  of  epithelial  cancer  of  the  nostril, 
septum,  and  upper  lip,  in  a  lady  of  seventy  years.  It  had 
become  distressing  to  herself  and  friends.  When  she  was 
referred  to  me  her  age  and  delicate  physique,  as  well  as  her 
dread  of  disfiguring  operation,  led  me  to  try  radium.  I  laid 
upon  the  diseased  part  Curie  radium  15  cgr.  300,000,  and  10  mgr. 
1,000,000,  this  would  represent  about  the  strength  of  20  mgr. 
of  the  present  standard  pure  German  radium  bromide.  This 
was  repeated  for  one  hour  on  ten  successive  days.  A  slight 
reaction  was  then  noticed,  and  treatment  stopped.  At  two 
weeks  the  edges  were  much  flatter  and  contracting,  while 
discharge  had  ceased  and  the  florid  granulation  changed  to 
a  gray  surface,  exuding  a  little  thin  lymph.  In  five  weeks 
the  entire  sore  had  healed,  and  only  a  thin  small  cicatrix 
remained.  These  three  stages  are  veritably  shown  in  the  ac- 
companying colored  casts  (Plate  xxi,  Fig.  i).  Two  years  have 
gone  by  and  the  patient  remains  cured  with  a  perfect  smooth, 
small  cicatrix. 

The  same  type  of  disfiguring  cancer  is  shown  in  another 
cast,  one  nostril  and  cheek  being  diseased.  This  patient  was 
sent  to  me  by  Prof.  Weir  to  see  if  a  disagreeable  plastic  opera- 
tion could  be  avoided.  Three  short  seances,  total  thirty-five 
minutes,  were  given  with  the  strongest  specimens  (amounting 
to  twelve  times  the  working  unit  of  10  mgr.  pure).  In  two 
days  it  already  had  begun  to  retrograde,  and  in  three  weeks 
was  entirely  and  permanently  healed. 

On  the  same  day,  nearly  two  years  ago,  another  man  was 


DERMATOLOGICAL  CONGRESS  463 

referred  from  the  same  surgeon,  for  a  similar  growth  which 
had  involved  one-third  of  the  upper  eyelid.  Three  five-minute 
stances  with  one  cell  of  pure  German  radium  bromide,  10  mgr. 
(working  unit),  permanently  cured  this  man  in  two  weeks. 

In  such  cases  I  protect  the  eye  by  thin  sheet  lead,  shaped 
like  a  spoon  handle,  covered  by  guttapercha  tissue,  and  slipped 
under  the  cocainized  eyelid,  between  which  and  the  radium  the 
diseased  part  is  compressed. 

I  show  you  also  many  other  colored  casts,  indicating  the 
condition,  treatment,  and  result.  A  large  proportion  of  these 
are  situated  upon  the  face,  neck,  and  ears.  These  are  not 
only  favorite  sites,  but  offend  by  their  disfigurement,  and  tax 
the  ingenuity  of  the  surgeon  to  remove  them  by  a  plastic 
operation  adequate  to  prevent  recurrence. 

Most  of  the  grave  cases  were  subjected  to  critical  micro- 
scopical study  before  treatment,  and  so  uniformly  found  to  be 
epithelial  carcinoma  that  in  minor  cases  I  have  trusted  clinical 
appearances,  which  to  me,  after  thirty  years  of  surgical  work, 
seem  worthy  of  confidence. 

The  accompanying  card  (Plate  xxi,  Fig.  2)  shows  a  face,  on 
which  I  have  charted  the  position  of  seventy-seven  cases  of  epi- 
thelioma  (or  lupus  that  has  in  parts  become  epitheliomatous) 
on  seventy  patients. 

This  represents  a  selected  typical  series,  but  by  no  means 
all,  which  I  have  treated  by  radium  for  this  particular  disease. 
Numbers  of  these  existed  for  years  as  keratosis  before  be- 
coming epitheliomata.  The  ordinary  senile  keratosis  has 
not  been  included  among  them,  but  forms  another  most  in- 
teresting series.  It  can  be  made  to  disappear  always  in  ten 
days,  after  one  application  of  twenty  minutes  of  the  working 
unit  of  radium. 

Of  the  epitheliomata  charted  above  I  may  say  that  I  have 
yet  to  see  one  case  which  did  not  show  retrograde  changes  soon 
after  treatment.  In  some  of  those,  however,  which  had  in- 
volved deeper  layers  than  the  cutaneous,  the  invasion  would 
sometimes  run  ahead  of  the  tissue  treated,  as,  for  example,  in 
the  orbit  where  the  eyelid  had  first  been  diseased,  and  a  mass 
had  grown  into  the  underlying  cellular  and  fatty  tissue  of  the 
orbit.  One  would  uniformly  see  a  superficial  cure  and  a  partial 


464  SIXTH  INTERNATIONAL 

deep  reduction.  Then,  after  some  weeks  there  followed  a  pro- 
gressive invasion  beyond  where  it  seemed  wise,  or  possible, 
to  treat  it  on  account  of  the  proximity  of  the  eyeball.  In 
such  cases,  therefore,  I  have  treated  the  case  up  to  this 
point,  and  then  thoroughly  removed  the  diseased  orbital 
contents. 

Epithelioma  of  the  eyelid,  when  confined  to  the  cutaneous, 
mucous,  or  glandular  structures,  seems  to  be  controlled  and 
cured  as  by  a  specific.  No  surgical  agent  has  yet  been  found 
so  efficient.  Even  small  specimens  of  i  milligram  of  strongest 
German  radium  bromide  have  shown  their  beneficent  action. 

As  a  further  note  preliminary  to  better  understanding  of 
the  unique  action  of  radium,  let  me  recall  its  value  in  treating 
warts.  The  curative  action  is  perfect  in  every  case,  no  matter 
how  inaccessible,  even  under  the  finger  nails,  or  how  large 
or  ancient.  A  radium  specimen  sealed  in  a  glass  tube  will 
always  cure  by  contact.  Even  on  the  soles  of  the  feet  where 
painful  callus  had  been  found  to  have  verrucous  base,  one 
application  of  radium  has  produced  prompt  cure  in  three  cases. 

In  melanotic  moles — either  congenital,  hypertrophic,  or 
hairy — the  action  of  radium  is  almost  specific,  and  with  this 
singular  coincident  action,  namely,  that  where  the  dosage  is 
graduated  correctly  the  hypertrophic  pigmented  tissue  atro- 
phies and  leaves  normal  appearing  skin.  Even  in  the  pig- 
mented skin  of  a  black  man  I  found  pink  skin  areas  defined 
the  points  of  contact  with  my  radium  tubes.  I  have  thought 
it  might  have  selective  action  for  pigment  layer  cells,  and 
might  be  used  in  melanotic  growths;  hence  I  have  used  it  in 
superficial  brown  moles,  coal-black  melanotic  moles,  recurrent 
nodules  of  melanotic  sarcoma,  melanotic  epithelioma  (pri- 
mary), and  on  thick-skinned,  hairy,  pigmented  moles.  The 
result  is  invariable — the  growth  and  pigmentation  uniformly 
retrograde. 

To  illustrate,  let  me  cite  a  case  of  pigmented  hairy  mole 
of  the  face.  Large,  hairy,  pigmented  mole  on  thick  brown 
skin,  covered  with  hair  like  a  mouse  skin,  in  which  were  a 
large  number  of  longer  hairs  i  to  i£  cm.  long.  Approaching 
this  novel  condition  with  caution,  I  began  in  June,  1906,  with 
the  strongest  tube,  60  mgr.,  pure  radium,  pressing  it  on  various 


DERMATOLOGICAL  CONGRESS  465 

parts  for  half  an  hour  at  a  time.  On  three  occasions  during 
two  weeks  I  applied  it  in  all  two  and  a  half  hours.  On  the 
following  week  a  sharp  reaction  occurred  with  blistering  and 
epilation.  Watching  the  results  of  each  treatment,  I  pro- 
ceeded with  such  slowness  that  during  nine  months  I  made 
thirteen  treatments,  a  total  of  eleven  hours  (nine  hours  of 
60  mgr.  tube  and  two  hours  of  10  mgr.  cell).  This  would 
represent,  therefore,  fifty-six  hours  if  I  had  used  only  a  10 
mgr.  tube. 

The  result  is  a  perfect  cure,  with  reduction  of  the  thick 
pigmented  skin  to  normal  quality  without  vestige  of  a  hair. 
At  one  stage  a  large  part  was  normal,  except  for  a  thin  coffee- 
colored  stain.  Assuming  that  some  pigmented  cells  were 
undertreated,  I  made  short  applications  of  radium,  and  the 
color  entirely  faded.  Had  I  to  treat  the  case  again  I  would 
apply  to  the  entire  surface  my  strongest  radium  tube,  60 
mgr.,  for  one  hour  each  week — not  pressing  it  longer  than  five 
minutes  on  any  one  spot.  I  believe  eight  stances  of  one  hour 
each  would  produce  a  cure — and  without  a  scar. 

Let  me  emphasize  the  retrograde  change  that  takes  place 
in  the  pigment  cells,  the  hair  bulbs,  and  cutaneous  gland 
structure.  In  other  words,  radium  has  changed  a  patch  of 
thick  skin  resembling  that  of  a  hairy  animal  to  human  skin. 

I  ask  attention  to  another  case  demonstrating  radium's 
unique  power.  The  casts  here  shown  (Plate  xxiii,  Fig.  4)  ac- 
curately depict  a  tumor  of  the  lower  lid  in  a  middle-aged  man, 
growing  more  than  a  year  (microscopically  a  small-celled  sar- 
coma) ,  which  had  progressively  grown  in  spite  of  careful  Roent- 
gen-ray treatment.  Four  times  I  laid  upon  it  some  little  sealed 
tubes  of  radium  (total  strength  20  mgr.  R.  Br.)  for  an  hour  each 
time  —  then  waited.  In  two  weeks  the  retrograde  change 
began.  In  four,  as  the  cast  shows,  it  had  undergone  rapid 
decline,  and  in  eight  weeks  it  was  gone.  The  patient  presents 
himself  for  you  to  see  that  after  two  and  a  half  years  he 
remains  absolutely  well  without  recurrence,  and  that  you  can- 
not distinguish  upon  which  eye  the  tumor  was  situated. 

In  the  spindle-celled  sarcomas  I  have  observed  an  arrest, 
but  not  a  decline  of  the  tumor,  and  will  at  present  say  nothing 
more  of  them. 


VOL.  I 30 


466  SIXTH  INTERNATIONAL 

But  in  a  group  of  so-called  giant-celled  sarcomata,  five 
in  number,  I  have  been  able  to  show  that  radium  has  what 
seems  to  me  to  be  a  distinct  specific  action. 

I  reported  in  1904  the  case  of  a  lad  in  whose  lower  jaw  the 
bone  was  practically  destroyed  at  one  part  and  replaced  by 
a  soft  purple  growth  —  sarcoma  rich  in  myelo-placques. 1 
Under  radium  stimulation  this  growth  was  rapidly  reduced  in 
bulk,  developed  ossific  points  throughout,  and  finally  became 
solid  with  new  bone.  The  boy  has  had  no  treatment  for 
three  and  a  half  years,  and  he  has  now  a  solid  jawbone. 

In  a  similar  condition  in  a  case  referred  to  me  by  Prof. 
E.  G.  Janeway,  an  elderly  lady  had  a  fracture  of  the  lower 
jaw  and  a  tumor  had  developed  at  its  site.  Several  treat- 
ments were  given  with  rapid  retrograde  of  the  tumor,  and  fine 
bony  union  resulted. 

In  a  lady  of  thirty  years,  prolific  development  of  soft  giant- 
cell  growth  of  both  upper  jaws  and  the  lower  right  jaw  has 
been  kept  in  check  by  radium  application  during  two  years. 
On  every  reappearance  of  the  purple  growth  it  promptly 
shrinks  after  one  or  two  applications. 

In  a  small  Italian  lad  the  entire  hard  palate  was  replaced 
by  a  soft  giant-celled  sarcoma;  it  expanded  the  upper  jaw 
and  was  not  less  than  3  cm.  in  depth.  Into  two  points  in  the 
mass  where  tissue  was  removed  for  microscopical  study,  the 
strongest  radium  tube  (60  mgr.  R.  Br.)  was  inserted  for  one 
hour  on  two  occasions.  Rapid  atrophy  of  the  whole  central 
mass,  and  ossification  of  the  remainder,  followed  in  a  few 
weeks — and  the  apparent  cure  continues  one  year 
after. 

In  a  fifth  case  a  bleeding  growth  began  between  the  incisor 
and  canine  tooth — microscopically  shown  to  contain  giant 
cells.  Two  applications  of  radium,  20  mgr.  R.  Br.,  total 
one-half  hour,  gave  prompt  arrest  of  hemorrhage  and  shrink- 
age of  the  growth. 

The  force  issuing  from  an  hermetically  sealed  tube  of 
radium  consists  of  certain  obscure  radiations,  to  which  the 
name  beta  and  gamma  rays  has  been  applied,  the  former 
carrying  a  charge  of  negative  electricity,  the  latter  being 

1  See  Medical  Record,  August  27,  1904. 


DERMATOLOGICAL  CONGRESS  467 

without  apparent  electric  charge.  (The  alpha  rays  carry 
a  positive  charge,  but  have  such  little  penetrating  power  that 
they  cannot  escape  through  the  glass.) 

The  beta  and  gamma  rays  are  indistinguishable  in  their 
physical  character  from,  on  one  hand,  the  electrons  thrown 
off  by  the  negative  disk  of  the  Roentgen  tube,  and,  on  the 
other,  the  rays  emanating  from  the  tube  (Lodge). 

It  is  easy  to  distinguish  two  methods  of  radium  action. 
One,  the  specific  retrograding  effect  on  neoplasms,  whose 
essential  substance  is  an  erratic  overgrowth  of  epithelial,  em- 
bryonal, or  glandular  structures.  (The  latter  is  seen  in  parotid 
or  thyroid  tumors,  where  extraordinary  changes  are  occa- 
sionally produced  by  radium,  though  its  precise  limitations 
cannot  yet  be  assigned.) 

The  other  effect  is  seen  in  the  occlusive  blockade  of  highly 
vascular  tumors  by  irritant  action,  as  in  naevi  and  large 
angiomata. 

That  its  power  does  not  reside  alone  in  producing  local 
inflammation  is  shown  by  its  effect  on  dry  seeds,  whose  life 
force  is  changed  by  exposure  to  it,  so  that  growth  is  retarded 
after  planting,  in  proportion  to  the  time  of  exposure. 

Also  in  animal  life,  as  illustrated  in  meal  worms,  where 
radium  so  represses  them  that  they  go  on  living  as  meal  worms, 
"  veritable  Methuselas, "  as  it  has  been  said,  while  their  sisters 
and  brothers,  unradiumized,  progress  for  generations,  com- 
pleting several  cycles  of  beetles,  eggs,  meal  worms,  etc. 

Of  radium  action  on  bacteria,  it  is  enough  to  show  two 
culture  plates,  upon  whose  central  part  strongest  radium 
has  been  playing  through  sterile  paper  for  fifteen  hours.  The 
colon  bacillus  and  Staphylococcus  aureus  growth  was  checked 
thereby  only  in  the  immediate  vicinity  of  the  radium,  after 
this  very  long  exposure.  In  one  a  lead  strip  was  interposed 
and  growth  occurred  beneath  it. 

The  time  needed  to  destroy  bacterial  life  in  these  cultures 
makes  it  improbable  that  the  good  action  of  radium  can  be 
considered  bactericidal  in  malignant  growths  (even  if  these 
had  been  proved  to  be  of  bacterial  origin) ,  because  that  length 
of  exposure  would  destroy  all  living  tissue  at  the  site  of  appli- 
cation. Practically,  the  best  results  are  seen  when  a  tenth 


468  SIXTH  INTERNATIONAL 

of  this  force  is  used  and  no  necrosis  of  tissue  follows.  It  is 
improbable,  therefore,  that  its  value  is  due  in  any  large  degree 
to  its  bactericidal  power. 

I  invite  your  attention  one  moment  to  a  very  practical 
point,  a  simple  and  accurate  method  of  measuring  the  power 
of  radium  specimens.  Investigators  have  used  extremely 
variable  strengths  and  amounts  of  this  precious  mineral. 
It  is  fair  to  say  that  moderately  strong  specimens  may  be 
effectually  used,  but  that  very  weak  ones  show  uncertain 
results.  Hence,  a  standard  may  well  be  adopted,  and  must 
be  put  at  the  present  time  as  10  mgr.  of  the  German  pure 
radium  bromide,  strength  denominated  i, 800,000. *•  Let  us 
call  this  the  "working  unit." 

Inasmuch  as  innumerable  variations  from  this,  both  in 
weakness  and  quantity,  are  in  use,  we  must  have  a  fair  gauge — 
and  I  offer  the  photograph  plate  as  the  easiest  and  most 
accurate  test  (Plate  xxii,  Fig.  3). 

I  have  graphically  shown  my  method  of  determining  the 
working  value  of  an  unknown  specimen.  Enclose  a  sensitive 
dry  plate  in  two  black  paper  envelopes  and  mark  across  the 
paper  two  series  of  squares,  writing  in  each  the  numbers  5, 
10,  15,  20,  30,  40,  50,  60;  cover  the  surface  with  sheet  lead 
in  which  a  corresponding  square  is  cut.  Place  this  over  the 
first  square  and  suspend  above  it  the  standard  10  mgr.  R. 
Br.  held  at  a  fixed  distance  by  a  bent  piece  of  lead.  With  a 
stop-watch  in  hand,  expose  it  five  seconds,  move  the  open  lead 
to  the  second  square,  expose  10  seconds,  and  so  on  for  all. 
Repeat  these  exposures  on  the  second  series  of  squares,  using 
the  unknown  specimen  of  radium  for  the  same  exact  times 
as  the  standard.  When  the  photograph  plate  is  developed 
one  sees  two  series  of  squares  delicately  shaded  exactly  in 
proportion  to  the  time  of  exposure. 

Observe  that  a  shade  of  standard  five-second  exposure 
is  identical  with  that  of  the  unknown  specimen  of  thirty 
seconds.  We  have  accurate  value,  then,  for  the  working  force 
of  the  unknown,  which  will  require  six  times  the  length  of 
exposure  to  a  tumor  as  the  standard. 

Having  established  the  working  value  of  a  specimen  of 

»  Obtainable  from  Hugo  Lieber,  i  Platt  Street,  New  York. 


DERMATOLOGICAL  CONGRESS  469 

radium,  one  may  'produce  the  results  which  one  sees  from  the 
working  unit  of  10  mgr.  R.  Br.  (1,800,000)  as  follows: 

1.  If  this   be   placed  upon  the  skin   for    ten     minutes 
nothing  will  be  seen  for  a  week.     Then  a  pink-red  spot  ap- 
pears, with  itching  and  burning.     After  two  weeks  it  has  gone. 

2.  Exposure  of   thirty  minutes.     Burning,    itching,   and 
redness  occur  in  three  days,  are  more  severe,  and  last  two 
weeks.     If  an  epithelial  growth  has  been  treated,  its  retro- 
grade begins   about  the  tenth  day.     In   previously  painful 
tumors  the  pain  usually  stops. 

3.  If  an  ulcerated  surface  be  treated,  or  a  strong  radium 
tube  be  inserted  in  a  wound  for  twenty-four  hours,  there  will 
result   a   specific   toxemia   in   many   cases.     The   symptoms 
will  be  headache,  chill,  general  aching,  coated  tongue,  fever 
up  to  from  103°  to  106°  F.,  and  an  occasional  rash  like  that 
of  scarlatina. 

In  six  cases  that  were  perhaps  overtreated,  I  have  seen  a 
spreading  rash  resembling  erysipelas  starting  at  the  diseased 
ulcer,  and  subsiding  after  two  or  three  weeks. 

In  all  cases  of  severe  reaction  the  sequel  has  been  favorable. 
In  two,  however  (one  cancer  of  the  tonsil  and  one  of  the 
tongue),  I  thought  the  patient  not  as  well  for  a  time  afterward. 
But  reviewing  all,  I  can  definitely  state  that  I  have  never  seen 
harm  follow  the  use  of  strongest  radium.  On  the  other  hand, 
the  curative  effect  of  severe  reaction  healed  a  large,  deep 
angioma  of  the  parotid,  after  grave  toxic  symptoms,  with 
temperature  106°  F. 

At  first  I  thought  the  toxemia  might  be  favorable,  owing 
to  absorption  into  the  lymphatics  of  a  self-generated  toxin 
(or  antitoxin)  along  the  line  of  preceding  disease  absorption. 
This  hypothesis  was  disproved  by  two  facts;  first,  that  sub- 
sequent examination  of  axillary  glands  removed  from  a  patient 
with  a  mammary  scirrhus,  who  had  had  a  lively  toxic  re- 
action, showed  the  disease  still  present  in  them,  while  the 
breast  tumor  had  atrophied.  Second,  that  the  same  toxemia 
occurred  while  treating  a  case  of  goitre  and  one  of  parotid 
tumor,  in  which  a  radium  tube  had  been  inserted  with  lively 
effect.  Here  was  no  chance  for  antitoxin  generated  from 
malignant  growth. 


47o  SIXTH  INTERNATIONAL 

I  may  say  that  my  glass  tubes  are  always  cleansed  and 
immersed  in  95  per  cent,  carbolic  acid,  followed  by  alcohol — 
both  after  and  before  using — so  that  no  infective  toxemia 
would  be  likely  to  occur.  I  conclude,  therefore,  that  fever 
is  due  to  cell  necrosis  close  to  the  strong  radium  tube,  and  not 
from  liberation  of  a  toxin. 

In  what  does  the  beneficent  action  of  radium  reside? 
This  question,  with  many  others,  still  awaits  solution. 

We  know  only  that  we  have  a  subtle  force,  which,  as 
far  as  we  discern,  is  a  stream  of  rays  charged  with  negative 
electricity  with  intense  penetrative  power,  capable  of  traversing 
stone,  human  flesh,  or  solid  steel  with  facility,  which  plays  upon 
the  vital  cells  (animal  or  vegetable)  and  alters  their  rate  of 
growth,  or  kills  them  altogether. 

What  the  vital  spark  is  in  a  living  thing  no  one  knows. 
It  has  been  surmised  that  life  itself  may  only  be  an  embodiment 
of  electric  force.  It  has  been  supposed  by  some  that  a  living 
cell  continues  its  normal  career  owing  to  a  balance  established 
within  it  between  positive  and  negative  electric  force,  and  that 
an  aggregate  mass  of  cells  in  the  body,  such  as  constitutes  a 
tumor,  may  result  from  their  erratic  growth  owing  to  a  loss 
of  balance  of  electric  equilibrium.  May  it  not  be  reasonable  to 
suppose  that  a  mild  application  of  radium  emitting  its  distinc- 
tive rays  is  thereby  capable  of  restoring  the  electric  equilibrium, 
while  on  the  other  hand  a  prolonged  and  intense  application 
carries  the  balance  to  a  destructive  termination  ? 

Consider  for  a  moment  that  remarkable  case  you  have  seen 
of  the  tumor  of  the  eyelid.  It  had  displaced  the  normal  skin 
and  mucous  membrane,  and  grown  in  bulk  many  times  the 
size  of  tissues  that  had  been  lost  in  it.  There  was  no  semblance 
of  an  eyelid  in  the  mass  whose  tuberous  growth  rose  in  heaped- 
up  masses  on  the  skin,  and  within,  and  on  the  edge. 

A  cross-section  would  have  shown  no  vestige  of  former 
tissues  which  were  destroyed  or  lost  in  the  mass.  Yet,  when 
retrograde  was  finished  under  radium  action,  behold  the 
normal  skin  structure,  the  normal  edge  of  the  eyelid,  normal 
mucous  membrane,  normal  glands  and  eyelashes !  The 
original  cells  wrere  not  destroyed.  There  was  a  reassembling 
out  of  the  conglomerate  diseased  mass.  Whence,  then,  came 


PLATE  XXI. To  Illustrate  Dr.  Eobert  Abbe's  Article. 


FIG    1. — Epithelioma  of  the  nose  and  upper  lip,  showing  diminution  at  the  end  of  two  weeks, 
and  disappearance  at  the  end  of  five  weeks. 


FIG.  2 — Showing  the  location  of  tin-  rpitheliomata  treated 
by  radium  in  77  ca- 


PLATE  XXII.— To  Illustrate  Dr.  Robert  Abbe's  Article. 


jerman  (Stahmer) 


Radium  Bromide. 
(i,  800,000) 


French  (Curie) 
Radium  Bromide. 
(200,000) 


Radium  Barium 
Chloride  (300,000) 


Seconds  of  Exposure. 

60  50  40  50  20  15 


Standard 
Working  Unit. 


60  mg. 


20  mg. 


•••••III 
Illlllll 

Illlllll 
Illlllll 


FIG.  S.— Radioautograpbic  estimate  of  the  working  value  of  radium 


PLATE  XXIII.— To  Illustrate  Dr.  Robert  Abbe's  Article. 


DERMATOLOGICAL  CONGRESS  471 

the  diseased  cells  ?  This  can  be  answered  only  by  the  assump- 
tion that  an  intercellular  in  visible"  and  ultramicroscopic  system 
of  particles  had  existed  with  a  life  of  their  own,  constituting  a 
network  holding  the  visible  cells  together.  This  system,  then, 
had  itself  taken  on  an  erratic  growth  and  become  a  sarcoma 
mass,  engulfing  the  regular  occupants  of  the  ground. 

Conclusions. — Radium  ranks,  not  with  caustics,  cautery, 
antiseptics,  or  medication,  but  with  specifics. 

This  does  not  mean  a  "specific"  for  cancer,  in  the  popular 
sense,  but  for  erratic  cell  growths  constituting  some  types 
of  tumor  tissue  in  the  earlier  stage  of  invasion,  or  of  moderate 
development. 

Details  of  the  methods  of  using  it  have  not  yet  been  fully 
worked  out.  The  dosage,  so  to  speak,  or  time  of  exposure 
necessary  for  curative  action,  is  as  yet  empirical. 

Some  apparent  cures  of  small  epitheliomas  or  sarcomas 
have  endured  already  more  than  three  years. 

A  photographic  plate  provides  a  good  test,  to  show  the 
working  force  of  an  unknown  specimen,  in  comparison  with 
one  of  standard  strength. 

It  is  not  entirely  a  mysterious  force — but,  in  part  at 
least,  is  an  electric  discharge,  essentially  of  negative  elements. 
Hence,  as  far  as  it  is  possible  to  say,  it  suggests  a  theory  of  its 
action,  in  that  it  may  supply  an  element  of  electric  force  vital 
to  normal  and  orderly  growth,  the  loss  of  which  may  have 
caused  a  disorderly  cell  growth  which,  in  the  aggregate,  con- 
stitutes tumor  masses. 

It  is  supplementary  to  Roentgen  rays,  and,  in  some  cases, 
is  efficient  where  they  fail. 

The  overaction  of  strong  radium  is  destructive  and  vitiates 
the  benefit  of  moderate  use. 

The  best  results  have  followed  one  hour's  exhibition  of  the 
working  unit  (10  mgr.  R.  Br.)  on  small  growths,  and  three 
to  four  hours  on  larger  ones,  with  an  interval  of  one  month 
for  study  of  the  effect. 

Ischemia  of  the  parts  during  treatment  greatly  enhances 
its  action. 

Pigmented  moles,  melanotic  growths,  and  giant-cell  sarcoma, 
like  epitheliomata  of  the  eyelids,  face,  and  body,  are  particularly 


472  SIXTH  INTERNATIONAL 

susceptible  to  its  curative  action — as  a  specific  agent.  But  its 
value  in  naevoid  and  angiomatous  tumors  is  due  to  its  irritant 
action,  producing  obliterating  endarteritis  and  fibroid  changes. 


SUR  L'ACTION  DU  RADIUM  DANS  L'EPITHE- 
LIOMA  CUTANE.  ETUDE  FAITE  AU  LABO- 
RATOIRE  BIOLOGIQUE  DU  RADIUM 

PAR  LE  DR.  Louis  WICKHAM  ET  LE  DR.  DEGRAIS,  PARIS 

La  note  que  nous  apportons  au  Congres,  sur  le  traitement 
de  r6pithe"lioma  cutane  par  le  RADIUM,  est  detachee  d'une 
etude  generale  que  nous  poursuivons  depuis  plusieurs  annees 
sur  I'emploi  du  RADIUM  dans  les  maladies  de  la  peau. 

Cette  etude  comporte  environ  1500  applications  reparties 
sur  no  malades,  la  plupart  de  la  classe  hospitaliere,  qui  nous 
ont  ete  adresses  par  nos  amis  et  maitres  des  hopitaux. 

Elle  a  mis  en  evidence  le  pouvoir  complexe  qu'a  la  radio- 
activite  d'analgesier  les  tissus,  de  les  decongestionner  de  devier 
dans  leur  evolution  morbide  les  cellules  alter6es  et  meme 
de  les  detruire. 

Elle  nous  a  montre  que  ce  pouvoir  pouvait  etre  utilise 
en  divers  groupes  de  la  pathologic  cutanee  particulierement 
dans : 

i°.  Certaines  formes  de  dermatoses  chroniques  superficielles, 
seches,  localisees,  rebelles  (comme  certaines  formes  d'ecze"mas, 
d'eczematisation  et  de  lichenification,  certaines  formes  de 
nevro-dermites,  de  lichen  ruber  plan  et  de  psoriasis)  avec  action 
analgesique  particulierement  favorable  sur  1' element  prurit 
de  quelques-unes  de  ces  dermatoses. 

2°.  Certaines  formes  de  nasvi  vasculaires  et  pigmentaires. 

3°.  Et  dans  les  epitheliomas  cutanes  et  cutan£o-muqueux. 

C'est  a  ce  denier  groupe  que  nous  limitons  notre  com- 
munication;  nos  Etudes  ont  porte  sur  41  Epitheliomas  dont  un 
certain  nombre  sont  en  cours  de  traitment. 

Nos  appareils  ont  et6  analyses  par  M.  Baudouin,  prepara- 
teur  de  Physique  au  Laboratoire  Biologique  du  RADIUM  aussi, 
connaissant  les  rayonnements  utilisables,  ceux  qui  penetrent  les 


DERMATOLOGICAL  CONGRESS  473 

tissus,  nous  avons  pu,  en  tenant  compte  de  la  dure'e  et  du 
nombre  des  applications  indiquer  pour  chaque  resultat  obtenu 
la  dose  et  la  nature  de  la  radio-activit6  employee. 

Si  M.  Danlos,  depuis  ses  travaux  de  1905,  a  pu  conside"rer 
le  RADIUM  comme  le  traitement  de  choix  des  petits  can- 
croides,  1'attention  n'a  pas  e"te"  attire"e  sur  Faction  du  RADIUM 
dans les  e"pitheliomas  plus  importants  ni  sur  la  question  du  dosage- 
Nous  insisterons  surtout  sur  ces  deux  points. 

Le  dosage  est  d'une  utilite"  primordiale.  II  indique  1'activite" 
du  sel  de  RADIUM  utilise"  et  surtout  la  radiation  exte"rieure 
de  1'appareil  employe,  celle  correspondant  a  la  quantit^  de 
rayons  qui  pene"treront  les  tissus — I'activite'  initiale  est  en 
effet  diminuee  du  fait  de  1'incorporation  du  sel  de  RADIUM  a  un 
vernis  special  destine  a  fixer  le  sel  sur  1'appareil. 

Le  dosage  donnera  aussi  la  teneur  en  rayons  «,  ft  et  y, 
tous  utilises  dans  le  traitement  de  1'e'pitrie'lioma. 

Grace  a  ces  donnees,  nous  pourrons  suivant  les  caracteres 
objectifs  d'un  6pithelioma  indiquer  quel  sera  le  temps  d'ap- 
plication  utile  pour  obtenir  la  gu Prison. 

Ces  temps  d'application  seront  variables  suivant  que 
Ton  aura  a  faire  a: 

Un  epithe'liomabourgeonnant,  ulcero-crouteux  a  evolution 
torpide,  terebrant. 

Prenant  pour  type  d'appareil  un  appareil  de  1  cent.  £  de 
diametre  contenant  0.025  de  sulfate  de  RADIUM,  ayant  comme 
activit^  500,000,  une  radiation  ext6rieure  de  62,000,  et  conte- 
nant 2  %  <*,  84  %  ft  et  14%  y,  nous  pouvons  approximative- 
ment  evaluer  a: 

Sept  a  8  heures  le  temps  utile  pour  1'e'pithe'lioma  bourgeon - 
nant,  dans  ce  cas  les  cellules  jeunes  de  proliferation  sont  plus 
facilement  influences. 

Dans  r<§pithelioma  ulcero-crouteux  qu'il  faudra  toujours 
avoir  soin  auparavant  de  d£barrasser  de  sa  croute,  la  surface 
ainsi  mise  k  nu  est  exulc£ree  avec  une  bordure  de  perles  6pi- 
theliales  et  un  centre  legerement  cupuliforme  dans  ce  cas,  10 
a  1 2  heures  d'application  en  moyenne  seront  utiles. 

Enfin,  dans  la  forme  t£re"brante  a  bords  tail!6s  a  remporte 
piece  avec  depression  profonde  et  fond  atone,  14  heures  environ 
deviendront  ne"cessaires. 


474  SIXTH  INTERNATIONAL 

Les  stances  seront  de  i  heure  a  2  heures  tous  les  jours 
ou  tous  les  2  jours. 

Quinze  jours  a  3  semaines  apres  la  derniere  application  com- 
mencent  les  pheriomenes  de  reaction.  Ceux-ci  consistent  en 
1'apparition  d'une  croute  melliforme  plus  ou  moins  epaisse 
reposant  sur  une  petite  nappe  de  pus.  La  croute  n'adhere 
que  tres  peu  a  sa  pe'riphe'rie  et  il  est  facile  en  appuyant  l£gere- 
ment  a  son  centre  de  constater  qu'elle  repose  sur  un  plan 
fluctuant  et  en  meme  temps  de  faire  sourdre  i  ou  2  petites 
gouttelettes  purulentes.  Pendant  la  presence  de  cette  croute 
il  existe  aussi  un  suintement  parfois  assez  abondant  de  sero- 
site".  Le  malade  ressent  pendant  cette  phase  une  sensation 
de  chaleur  assez  vive. 

Si  on  souleve  cette  croute,  ce  qui  est  tou jours  facile,  on 
voit  la  nappe  purulente  qui,  une  fois  enlev6e,  laisse  a  d£couvert 
les  tissus  de  reparation.  Ceux-ci,  de  couleur  rosee,  comblent 
assez  rapidement  les  cavit6s  qu'avait  creuse  la  neoplasie,  et, 
signe  tres  caracteristique,  la  lesion  qui  saignait  facilement, 
ne  saigne  plus. 

Comme  soins  a  donner  a  cette  reaction  1'application  de 
vaseline  borique"e  suffit  habituellement,  mais  si  la  suppuration 
tend  a  devenir  par  trop  abondante,  quelques  attouchements 
a  1'eau  d'Alibour  de"doub!6e  rendront  des  services  appr£ciables. 

La  croute  peut  se  reformer  plusieurs  fois  mais  chaque 
fois  Ton  constate  qu'elle  est  moins  epaisse,  que  la  suppuration 
diminue  et  que  1'ecoulement  de  s6rosit6  se  tarit. 

Enfin,  entre  la  6&me  et  la  Seme  semaine  la  croutelle  exist  ante 
enlevee  facilement  sera  remplace'e  par  une  cicatrice  que 
te'moignera  de  la  gue'rison. 

Pendant  quelques  temps  encore  la  surface  sera  le  siege  de 
squames  le"geres  qui  peu  a  peu  disparaitront. 

Et  alors,  tandis  que  dans  les  formes  bourgeonnantes  la 
fonte  progressive  de  la  tumeur  rendra  aux  organes  leur  forme 
et  leur  niveau  primitifs  dans  les  autres  vari6tes  1'arret  du 
processus  destructeur  permettra  aux  tissus  un  bourgeonne- 
ment  qui  nivellera  la  lesion. 

II  est  bien  entendu  que  toutes  les  indications  donne"es 
au  sujet  du  temps  d'application  devront  varier  en  plus  ou  en 
moins  suivant  1'activite"  plus  ou  moins  grande  du  sel  employ^. 


DERMATOLOGICAL  CONGRESS  475 

II  est  aussi  possible  de  proce"der  par  me~thode  seche,  avec 
des  temps  d'application  tres  courts  et  r6it6r6s,  on  evite  ainsi 
les  reactions  mais  le  traitement  y  perd  en  rapidite". 

Les  epitheliomas  que  nous  avons  eu  a  traiter  siegeant 
presque  tous  a  la  face,  la  question  de  la  cicatrice  joue  un 
r61e  considerable  et  celles  obtenues  par  la  RADIUMTHERAPIE 
meritent  qu'on  s'y  arrete  un  instant;  dans  tous  les  cas,  on 
obtient  une  surface  de  reparation  qui  est  lisse,  de  niveau 
avec  les  tissus  sains  peripheriques ;  la  coloration  d'abord  un  peu 
blanchatre  ne  tarde  pas  a  prendre  une  teinte  presque  normale ; 
au  toucher,  on  a  une  sensation  de  souplesse  appreciable  dans  le 
cas  ou  les  lesions  siegent  pres  des  orifices  et  jamais  en  effet  on 
a  a  faire  a  une  cicatrice  retractile  qui  pourrait  entrainer  des 
deformations  prejudiciables  a  1'esthetique. 

Celle-ci  est  si  parfaite  que  parfois  il  devient  impossible  de 
retrouver  les  traces  de  1'ancienne  lesion. 

Le  second  point  interessant  concerne  les  epitheliomas  de 
grandes  dimensions. 

Nous  avons  pu  les  faire  beneficier  de  la  RADIUMTHERAPIE 
par  1'emploi  d'un  appareil  mesurant  6  cent,  de  diametre, 
contenant  0.20  de  sulfate  de  RADIUM  ayant  une  activite 
de  500,000,  une  radiation  exterieure  290,000  a  300,000  conte- 
nant 10%  a  75  a  80%  ft  et  10  a  15%  y,  et  le  champ  du  traite- 
ment de  choix  des  petits  epitheliomas  peut  s'eiargir  et  englober 
les  grands  epitheliomas. 

Le  RADIUM,  source  merveilleuse  de  rayons  curatifs,  aura 
parfois  1'avantage  de  pouvoir  etre  utilise  la  ou  d'autres  traite- 
ment s  ne  peu  vent  trouver  leur  emploi,  grace  aux  formes  mul- 
tiples que  peuvent  revetir  les  appareils  porteurs  de  RADIUM. 

Un  appareil  termine  par  une  petite  sphere  nous  a  permis 
de  traiter  un  cul  de  sac  conjonctival  envahi  par  un  epitheiio- 
ma  d'abord  cutane. 

Une  lame  plate  nous  fac;lite  le  traitement  de  la  face  con- 
jonctivale  des  paupieres,  et  avec  un  appareil  cylindrique 
nous  penetrons  dans  le  conduit  auditif. 

L'application  des  appareils  peut  etre  directe;  leur  desin- 
fection  pouvant  se  faire  d'une  maniere  fort  simple  en  les 
soumettent  aux  vapeurs  de  formol,  mais,  pour  preserver  le 
vernis  qui  quoique  tres  resistant  pourrait  a  la  longue  se  deterio- 


476  SIXTH  INTERNATIONAL 

rer  du  fait  du  contact  prolong^  avec  des  surfaces  humides, 
nous  enveloppons  les  appareils  dans  une  feuille  de  baudruche. 

La  preservation  des  tissus  sains,  quand  les  dimensions 
de  1'appareil  ne  correspondent  pas  a  celles  de  I'epithelioma, 
se  fait  avec  une  feuille  de  plomb  ou  de  plomb  caoutchout6  dans 
laquelle  on  fait  une  lumiere  de  la  grandeur  de  la  lesion. 

Comme  precaution  complementaire,  il  sera  prudent  d'in- 
terposer  entre  le  plomb  et  la  peau  une  feuille  de  papier  ou 
d'aluminium  car  la  face  posterieure  du  plomb  devient  le  siege 
d'une  emission  de  rayons  secondaires  provenant  de  la  trans- 
formation des  rayons  primaires. 

Avant  de  conclure,  nous  signalerons  la  gue"rison  obtenue 
dans  un  cas  d'epithelioma  bourgeonnant  de  la  levre  inferieure 
situ6  un  quart  sur  la  portion  rouge  de  la  levre  et  trois  quart 
sur  la  face  muqueuse  buccale. 

Les  resultats  que  nous  avons  obtenus  nous  permettent: 

i°.  De  confirmer  la  formule  traitement  de  choix  appliqu6e 
par  M.  Danlos  au  traitement  des  pet  its  cancroides  par  le 
RADIUM. 

2°.  Ces  resultats  d'autre  part  elargissent  le  champ  d'action 
du  RADIUM  et  montrent  qu'avec  des  appareils  appropri6s  ce 
champ  d'action  s'etend  a  des  epitheliomas  qui  comme  siege, 
comme  dimensions,  comme  caracteres  rebelles,  depassent  les 
faits  decrits  jusqu'ici. 

3°.  Le  RADIUM  a  une  certaine  election  sur  la  cellule  can- 
cereuse,  puisqu'en  certain  cas  il  peut  la  modifier  ou  la  detruire 
sans  produire  d'ulceration  cliniquement  visible  ni  alt6rer 
sensiblement  les  tissus  sains  voisins. 

4°.  Les  applications  sont  faciles,  1'esth  etiquedes  tissus  de 
reparation  est  tres  satisfaisante,  elle  atteint  parfois  la  per- 
fection. 

5°.     Notre  etude  realise  un  premier  essai  de  dosage. 

Le  RADIUM  s'offre  done  comme  un  moyen  de  plus  qui 
vient  d'une  part  s'ajouter  aux  traitements  par  les  rayons  X 
les  ablations  chirurgicales,  les  caustiques  et  qui  d'autre  part 
peut  se  combiner  avec  eux. 

II  offre  des  avantages  qui  lui  sont  personnels  pour  certaines 
localisations  peu  accessibles  aux  autres  moyens. 

Un  mot  encore,  I'int6ret  qu'il  y  a  a  6tablir  1'action  curative 


DERMATOLOGICAL  CONGRESS  477 

des  rayonnements  du  RADIUM  en  un  point  quelconque  de  la 
pathologic  cutane"e  elevant  bien  au-dessus  du  fait  en  lui-meme 
la  question  de  la  RADIUMTHERAPIE. 

En  effet  ne  peut-on  espeYer  que  s'ils  peuvent  etre  ported 
dans  les  profondeurs  de  1  economic,  ces  rayons  ne  puissent 
modifier  aussi  et  de  m£me  facon  les  tissus  morbides  de  nature 
analogue  ? 

Or,  c'est  la  un  espoir  qui  n'est  point  actuellement  sans 
base ;  nous  avons  pratique"  nombre  d'injections  souscutane"es  et 
intramusculaires  de  solutions  contenant  du  RADIUM  et  nous 
avons  constate  que  ces  injections  etaient  bien  supportees,  du 
moins  aux  doses  utilisees;  et  nous  avons  d'autre  part  obtenu 
certains  resultats  encourageants  que  nous  avons  pre'sente's  a 
la  Societe  de  Dermatologie. 

Mais  cette  question  de  la  penetration  dans  I'^conomie 
de  l'e"nergie  radio-active  est  fort  complexe:  elle  comporte 
1' etude  chimique  d'energie  nouvelle,  de  I'^manation  et  de  la 
radio-activite  induite  qui  en  derive. 

Aussi,  cette  6tude  ne  peut  esperer  progresser  qu'a  la  double 
condition  d'etre  tres  6troitement  aid6e  par  la  collaboration  de 
laboratoires  de  Physique  et  Chimie  et  de  MMecine  Exp6ri- 
mentale  et  d'avoir  a  sa  disposition  les  elements  de  recherches 
necessaires. 

Ces  conditions,  nous  les  avons  trouv£es  re'unies  au  "  LABO- 
RATOIRE  BIOLOGIQUE  DU  RADIUM";  elles  nous  ont  paru  consti- 
tuer  des  elements  d'^tudes  de  haut  interet  et  nous  pnt  conduit 
a  y  poursuivre  nos  recherches. 

Discussion 

DR.  JAY  F.  SCHAMBERG,  of  Philadelphia,  said  he  wished  to  say 
a  few  words  in  regard  to  the  therapeutic  action  of  radium.  He 
had  listened  with  pleasure  to  Dr.  Abbe's  paper,  and  could  confirm 
his  results  in  the  treatment  of  cutaneous  growths,  particularly 
superficial  epitheliomata  and  warts.  The  question  arose,  how- 
ever, did  radium  do  any  more  in  these  conditions  than  the  X-ray? 
Unless  radium  could  be  shown  to  be  more  efficient  there  would 
be  no  special  advantage  in  preferring  its  use  to  that  of  the  X-ray. 
The  advantages  of  radium  are  in  the  simplicity  of  its  application, 
and  in  the  fact  that  it  can  be  used  in  inaccessible  cavities,  where 


478  SIXTH  INTERNATIONAL 

the  X-ray  can  not  be  applied.  If  we  were  able  to  bring  to  bear 
upon  a  malignant  growth  a  sufficiently  large  volume  of  X-rays 
without  causing  the  destruction  of  intervening  healthy  tissues, 
such  malignant  growths,  wherever  seated,  might  be  destroyed 
and  the  disease  cured.  Possibly  future  developments  in  the 
technique  of  the  application  of  the  rays,  perhaps  by  the  interpo- 
sition of  proper  nitration  media,  may  accomplish  something  in 
this  direction. 

Dr.  Schamberg  exhibited  a  radiogram  made  with  radium  and 
one  made  with  a  low-power  Crookes  tube  which  illustrated  the 
fact  that  the  radium  rays  passed  through  silver  much  more  readily 
than  did  the  X-rays. 

Dr.  Schamberg  also  showed  a  radium  holder  for  the  treatment 
of  favus  and  ringworm  of  the  scalp.  In  view  of  Sabouraud's 
brilliant  results  with  the  X-rays  in  the  treatment  of  these  diseases, 
the  speaker  felt  that  it  was  worth  while  trying  the  use  of  radium 
in  favus  and  ringworm.  The  quality  and  quantity  of  the  rays 
given  off  from  radium  were  so  much  more  constant  than  from  a 
Crookes  tube  and  the  application  a  process  of  such  simplicity 
that  this  means  of  treatment,  if  successful,  would  have  decided 
advantages  over  treatment  with  the  X-rays. 

DR.  H.  RADCLIFFE-CROCKER,  of  London,  said  that  Sir  William 
Ramsay,  the  eminent  chemist,  had  discovered  that  with  a  solution 
of  radium  there  was  decomposition  of  water  into  oxygen  and 
hydrogen,  with  certain  emanations  from  the  radium  itself  which 
had  important  physical  properties,  and  that  these  emanations 
could  be  conveyed  into  a  small  bulb,  together  with  the  oxygen 
and  hydrogen,  and  when  the  latter  gases  were  again  reduced  to 
water  the  emanations  could  be  dissolved.  The  speaker  said  he 
had  employed  this  agent  in  a  case  of  mycosis  fungoides,  and  under 
it  some  of  the  lesions  disappeared.  In  other  cases,  painful  in- 
durations would  form  at  the  point  of  the  injections;  these  lasted 
several  weeks  and  seemed  to  show  that  it  was  an  agent  of  very 
great  power.  The  speaker  said  he  asked  Sir  William  Ramsay 
how  much  radium  emanation  was  in  this  bulb,  and  he  replied  that 
the  amount  was  perhaps  one-fortieth  the  size  of  a  pin's  head. 
Some  of  this  agent  was  locally  applied  to  a  patch  of  psoriasis, 
which  completely  disappeared. 

Dr.  Crocker  said  he  was  unable,  from  the  paucity  of  the  ma- 
terial, to  continue  his  experiments  with  this  agent  for  any  length 
of  time,  and  at  present  it  could  simply  be  looked  upon  as  a  scientific 
curiosity. 


DERMATOLOGICAL  CONGRESS  479 

DR.  HERMAN  LAWRENCE,  of  Melbourne,  Australia,  said  that  some 
years  ago  he  was  fortunate  enough  to  obtain  five  specimens  of  ra- 
dium with  which  he  had  treated  a  number  of  cases.  In  cases  of 
rodent  ulcer  of  the  eyelid  he  regarded  radium  as  the  best  method 
of  treatment,  and  he  had  treated  several  such  cases  with  entire 
satisfaction,  particularly  as  it  removed  the  lesion  without  leaving 
a  scar.  Also  in  seborrhoeal  keratosis  senilis,  in  which  cases  there 
was  a  great  tendency  to  atrophy  of  the  skin  after  the  use  of  the 
X-ray.  The  speaker  said  he  had  also  employed  radium  to  ad- 
vantage in  the  treatment  of  pigmented  moles  and  in  seborrhoeal 
eczema  of  the  eyebrow,  where  the  X-ray  could  not  be  well  applied. 
His  experience  with  radium  had  led  him  to  the  conclusion  that  it 
had  its  place  in  certain  cases,  just  as  the  X-ray  and  the  knife  had. 

DR.  ROBERT  ABBE,  of  New  York,  said  that  in  the  further  dis- 
cussion of  his  paper  he  hoped  that  something  would  be  said  about 
the  pathological  results  of  the  radium  treatment.  In  cases  where 
lesions  had  disappeared  without  scarring,  what  was  the  patho- 
logical change  that  had  occurred  under  the  influence  of  the  radium 
rays?  They  seemed  to  exert  a  specific  action,  unlike  that  of  any 
other  therapeutic  agent  except  Roentgen  rays. 


THE  EFFECTS  OF  ROENTGEN  RAYS  ON  PAGET'S 
DISEASE  OF  THE  BREAST 

BY  DR.  ROBERTO  TERZAGHI  AND  PROFESSOR  ROBERT  CAMPANA, 

OF  ROME 

Some  forms  of  apparent  psoriatic  eczema  of  the  breast 
often  do  not  receive  medical  attention,  and  may  at  times 
assume  a  chronic  and  malignant  form,  as  an  epithelial  tumor, 
a  form  that  has  been  named  from  the  author  first  describing 
it,  "  Paget's  Disease."  It  is  not  about  the  nature  of  this 
affection  that  we  wish  to  speak,  but  simply  of  the  results  ob- 
tained with  Roentgen  rays  in  cases  that  threatened  to  assume 
the  above-named  form  of  disease. 

We  will  quote,  in  this  connection,  an  experiment  with 
the  relative  results  obtained  by  means  of  a  certain  number 
of  applications  of  Roentgen  rays  in  two  cases. 


480  SIXTH  INTERNATIONAL 

CLINICAL  HISTORY 

Diagnosis — Eczema  psoriasiform  of  the  breast  (incipient 
Paget's  disease).  Nutrition  good,  skeletal  development  regu- 
lar, stature  above  the  mean,  skin  somewhat  pallid.  The 
skin  of  the  chest,  the  nipples,  mammary  areolse,  and  adjacent 
parts  showed  a  slightly  humid  maculo-squamous  eruption; 
the  scales  were  broad  and  coriaceous,  indifferently  adherent, 
and  moist  on  the  lower  side,  the  underlying  skin  thickened, 
somewhat  hardened,  little  movable  in  its  different  layers,  and 
little  developed  on  the  subcutaneous  nipple.  Microscopic 
examination  of  the  scales  showed  no  pathogenic  mycotic 
forms;  there  were  the  usual  corpuscles  described  in  psoriasis. 
On  the  rest  of  the  body  a  few  lentiform  papules  at  very  great 
intervals  were  found  on  the  back  and  on  the  thighs.  Slight 
itching  sensation.  Genital  organs  normal.  No  pathological 
product  in  the  urine.  Different  functions  normal. 

The  affection  of  the  breasts  began  about  three  years  pre- 
viously and  the  patient  had  experienced  no  improvement 
from  various  methods  of  treatment  undergone  at  her  home- 

From  the  first  application  of  the  rays,  we  began  to  notice 
a  modification  in  the  resistance  of  the  cutaneous  epithelial 
cells  especially  at  the  periphery  of  the  mammary  areola, 
first  on  one  side,  then  on  the  other,  and  afterwards  on  the 
rest  of  the  periphery  of  the  nipple,  which  was  the  part  most 
affected;  more  persistent  adhesion  of  the  epithelium,  diminu- 
tion of  the  dermic  swelling;  not  remarkable,  yet  evident, 
return  to  their  normal  state  of  the  lines  and  folds  of  the  skin 
of  the  nipple;  gradual  diminution  of  the  humid  condition 
where  the  corneous  stratum  was  still  wanting. 

A  similar  line  of  treatment  was  followed  in  another  case 
with  the  same  favorable  results. 

These  two  experiments  do  not  seem  to  us  without  interest 
when  we  reflect  on  the  extremely  malignant  course  the  process 
assumes  in  sequence  to  phases  similar  to  the  cases  related 
by  us. 

Discussion 
DR.  NEUBERGER,  of  Nuremberg,  said  that  for  several  years  he 


DERMATOLOGICAL  CONGRESS  48i 

had  had  under  his  observation  a  case  of  Paget's  disease  of  the 
penis.  This  was  a  very  rare  condition,  only  two  cases  having  been 
recorded  prior  to  his  own.  The  diagnosis  in  this  case  was  con- 
firmed by  Prof.  Neisser  of  Breslau.  The  effect  of  the  X-ray  treat- 
ment in  this  case  was  in  the  beginning  very  marked,  and  the 
affection  apparently  was  cured.  It  subsequently  recurred,  how- 
ever, and  then  the  X-rays  had  seemingly  lost  their  effect.  The 
urethral  orifice  became  narrowed  so  that  micturition  was  impossible, 
and  amputation  finally  became  imperative. 

Dr.  Neuberger  said  the  case  was  a  good  illustration  of  the  fact 
that  the  X-rays  could  not  always  be  depended  on  to  exert  a  uni- 
formly good  effect,  even  in  the  same  case.  He  had  seen  the  same 
thing  occur  in  mycosis  fungoides,  where  for  a  time  the  lesions 
improved  under  the  use  of  the  rays,  but  which  afterwards  lost 
their  effect. 


DIE     INTRATUMORALE      BESTRAHLUNG     DER 

KREBSGESCHWULSTE    ALS    FORTSCHRITT 

DER    RADIOTHERAPIE 

VON  DR.  H.  STREBEL,  MUNCHEN 

Heute  steht  wohl  die  Tatsache  fest,  dass  Rontgen-,  Ra- 
dium- und  die  von  mir  in  die  Therapie  eingefuhrten  ausseren 
Kathodenstrahlen  imstande  sind,  das  Gewebe  von  Krebs-  und 
Sarkomgeschwulsten  zur  Ruckbildung  zu  bringen.  Ebenso 
fest  steht  aber  auch  die  Tatsache,  dass  unsere  heutige  Be- 
strahlungstechnik  nicht  imstande  1st,  jede  derartige  Geschwulst 
in  jeder  Grosse  und  jedesmal  zum  Schwund  zu  bringen.  Hier 
besteht  eine  Diskrepanz,  die  fur  uns  Rontgentherapeuten 
recht  argerlich  ist.  Wir  alle  kennen  wohl  die  Tatsache,  dass 
sich  besonders  bei  den  Sarkomen  oft  Geschwulste  gleichen 
histologischen  Charakters  den  Rontgenstrahlen  gegenuber 
different  verhalten,  so  dass  die  einen  auf  Bestrahlung  gut 
zuriickgehen,  die  anderen  aber  nicht.  Den  Grund  dieser 
auffallenden  Erscheinung  kennen  wir  nicht.  Zum  Teil  mag 
wohl  der  Umstand  schuld  daran  sein,  dass  Fehler  in  der  Technik 
vorliegen,  denn  nicht  jede  vorgenommene  Bestrahlung  muss 
schon  deswegen  wirksam  sein,  bloss  well  das  Rohr  leuchtet. 
Ob  das  Rohr  weich  oder  hart,  alt  oder  neu,  ob  die  fur  den  einzel- 

VOL.  I 31 


482  SIXTH  INTERNATIONAL 

nen  Fall  empirisch  notwendige  Strahlendosis  erreicht  1st 
oder  nicht,  spielt  naturlich  hierbei  eine  grosse  Rolle  und  wenn 
ein  neugebackener  Rontgentherapeut  ein  tuchtiger  Chirurg 
oder  Dermatologe  ist,  so  braucht  er  deswegen  nicht  auch  ohne 
Weiteres  ein  tiichtiger  Rontgentherapeut  zu  sein.  Aber 
diese  Momente  allein  konnen  nicht  ausschlaggebend  sein. 
Man  hat  lange  erkannt,  dass  das  Absorptionsverhaltnis  ira 
bestrahlten  Medium  einen  der  wichtigsten  Faktoren  fur  das 
Gelingen  der  Heilabsichten  darstellt.  Man  hat  z.  B.  gefunden, 
dass  in  bestrahlten  Krebsknoten  alle  Krebszellen  in  der 
Oberflachenschicht  bis  zu  einer  Tiefe  von  3  mm.  einschliesslich 
der  Epidermis  nicht  mehr  mikroskopisch  nachweisbar  sind, 
dass  tiefer  gelegene  Krebszellen  lediglich  Schrumpfungser- 
scheinungen  zeigen,  dass  bei  ca.  i  cm.  Tiefe  die  Wirkung  der 
Strahlung  vollkommen  aufhort,  die  Krebsnester  also  un- 
beeinflusst  geblieben  sind.  Eine  nur  etwas  ausgiebigere 
Tiefenwirkung  bei  intakter  Epidermis  ist  nur  unter  Nekro- 
tisierung  und  Erzeugung  chronischer,  schwer  heilender,  ge- 
ftirchteter  Geschwiirsbildung  moglich.  Wir  wissen  durch 
Wichmann,  Scholtz  u.  a.,  dass  die  Epidermis  -jV  der  gesamten 
Strahlung,  die  Kutis  mehr  als  die  Halfte  absorbiert.  So 
grosse  Strahlenmengen  gehen  also  bei  fokaler  Bestrahlung— 
ganz  abgesehen,  dass  nur  ein  Bruchteil  der  vom  Rohr  aus- 
geschickten  Strahlung  zur  Wirkung  kommt — nicht  nur  nutzlos 
verloren,  sondern  schadigen  sogar  die  Haut  und  beeintrachtigen 
so  den  ganzen  Effekt.  Die  Strahlendosis,  welche  bei  fokaler 
Bestrahlungsweise  von  der  Oberflache,  von  aussen  her  durch 
die  aussere  Haut  in  die  Tiefe  zum  Krebsgewebe  selbst  gelangt 
ist  daher  eine  verschwindend  kleine  und  da  ebenfalls  durch 
Wichmanns  verdienstvolle  Arbeit  bekannt  ist,  dass  Krebs- 
gewebe selbst  sehr  stark  absorbierend  wirkt,  so  ist  verstandlich 
warum  die  bisherige  Bestrahlungstechnik  bei  tiefsitzenden 
Tumoren  so  wenig  erreicht  hat.  Man  war  oft  sogar  in  der 
Lage  sehen  zu  miissen,  dass  ein  Krebstumor  auf  der  einen 
Seite,  wo  er  bestrahlt  wurde,  zuriickging,  nach  der  anderen 
Seite  jedoch  lustig  weiterwucherte. 

Mit  Riicksicht  auf  diese  Uberlegungen  habe  ich  schon 
1903  mein  Verfahren  der  intratumoralen  Radiumbestrahlung 
(D.  M.  Z.  1903,  No.  103)  veroffentlicht,  wobei  das  Radium 


DERMATOLOGICAL  CONGRESS  483 

in  die  ausgebohrte  Spitze  eines  Aluminiumstabchens  einge- 
schlossen  mit  Hilfe  eines  vorher  in  die  Geschwulst  selbst 
eingestochenen  Troikarts  direkt  in  das  Zentrum  der  Gesch- 
wulst eingefuhrt  wird.  (Siehe  auch  Wichmann,  D.  M.  W. 
1906,  No.  13.)  Dadurch  wird  der  Bestrahlungsrayon  ver- 
grossert  nach  alien  Richtungen  des  Raumes  gegeniiber  der 
nur  nach  vorne  wirkenden  fokalen,  epidermatischen  Applika- 
tion,  welche  die  von  der  Haut  abgewendete  Strahlung  nutzlos 
verlorengehen  lasst ;  die  Strahlung  kann  beliebig  lange  gesche- 
hen,  da  die  Rucksichtnahme  auf  Verbrennungen  der  Haut 
wegfallt ;  die  Strahlung  wirkt  vor  allem  viel  intensiver,  weil 
ja  die  ubermassig  starke,  nutzlose  Absorption  in  der  Haut 
vollstandig  wegfallt.  Dadurch  wird  mehr  als  die  Halfte 
der  Strahlung  wieder  nutzbar  verwertet  d.  h.  es  kommt  die 
ganze  Strahlung  zur  Wirkung  auf  das  Krebsgewebe.  Es 
ist  mittelst  dieser  intratumoralen  Applikation  des  Radium 
moglich,  auch  unter  der  Haut  gelegene  Metastasen,  Driisen- 
tumoren  wirksam  in  Angriff  zu  nehmen. 

Was  die  Rontgenstrahlen  anlangt,  so  hat  Wichmann 
den  Versuch  gemacht,  durch  in  Fistelgange,  in  den  Tumor 
selbst  eingeschobene  Bleiglasrohren  das  pathologische  Gewebe 
fokal  zu  bestrahlen.  Man  erreicht  so  jedoch  nur  kleine 
Bestrahlungsfelder,  es  wird  immer  nur  ein  Gewebszylinder 
bestrahlt,  dessen  Grossenverhaltnisse  dem  Querschnitt  des 
Rohrlumens  entsprechen. 

Es  ist  mir  nun  seit  ca.  i  Jahr  gelungen,  auch  die  Rontgen- 
strahlen intratumoral  zu  applizieren,  indem  ich  die  Strah- 
lungsquelle  selbst  in  die  Geschwulst  hineinverlegte.  Dies 
wird  ermoglicht  durch  Konstruktion  besonderer  Rohren. 
Bekanntlich  entstehen  die  Rontgenstrahlen  als  sekundares 
Produkt  der  auf  die  Antikathode  auftreffenden  Kathoden- 
strahlen.  Bei  meinen  neuen  Rohren  fallt  die  Spriegelanti- 
kathode  bekannter  Art  weg  und  ich  lasse  die  Kathodenstrahlen 
direkt  auf  die  Glaswand  an  einer  bestimmten  Stelle  fallen, 
diese  dadurch  zum  Ausschicken  von  Rontgenstrahlen  veran- 
lassend.  Gegeniiber  der  Kathode  ist  namlich  die  Glaswand 
zu  einem  spitz  zulaufenden  Rohr  ausgezogen,  auf  dessen 
Ende  die  Kathodenstrahlen  fallen  und  es  so  zum  Leuchten 
bringen.  Die  von  dieser  "  Glasantikathode "  ausgeheriden 


484  SIXTH  INTERNATIONAL 

Strahlen  gehen  entsprechend  der  Konstruktion  nach  alien 
Richtungen  des  Raumes  auseinander.  In  neuester  Zeit  habe 
ich  noch  eine  andere  Konstruktion  fertigen  lassen,  bei  der 
in  der  Spitze  eine  Platinantikathode  angebracht  ist,  wobei 
jedoch  die  ideale  Zerstreuung  der  Rontgenstrahlung  nach 
alien  Richtungen  nicht  erreicht  wird,  sondern  nur  eine  halb- 
kugelige.  Dieses  Rohr  kommt  speziell  fur  ganz  oberflachlich 
unter  der  Haut  gelegene  kleine  Tumoren  als  mehr  "  subkutane 
Applikationsweise "  in  Frage. 

Bei  der  intratumoralen  Applikation  wird  unter  Adrenalin- 
Schleichinfiltration  ein  zweischneidiges  Messer  senkrecht  oder 
in  anderer  Richtung,  ganz  entsprechend  den  anatomischen 
Verhaltnissen,  in  den  Tumor  eingestochen,  nachdem  man 
vorher  die  eventuell  noch  intakte  Haut  beiseite  gezogen  hat. 
Lasst  man  die  Haut  nach  geschehener  Applikation  entspannen, 
so  wird  die  Einstichoffnung  in  die  Haut  seitlich  von  dem 
Wundgang  im  Tumor  liegen,  also  ein  en  guten  Verschluss 
herbeifuhren.  Durch  den  in  den  Tumor  fuhrenden  Stichkanal 
schiebt  man  das  durch  Formalin  mit  nachfolgender  Alko- 
holabspulung  desinfizierte  Bestrahlungsrohr  ein,  spannt  das- 
selbe  entsprechend  in  ein  Stativ  und  fuhrt  nun  die  Bestrahlung 
durch.  Das  Adrenalin  sowohl,  wie  der  vom  Rohr  auf  das 
Gewebe  selbst  geiibte  Druck  schaffen  eine  tunlichste  Blutleere, 
wodurch  ein  weiterer  Faktor  fur  betrachtliche  Absorption  der 
Strahlung  ausgeschaltet  wird.  Die  von  der  Spitze  des  Rohres 
ausgehende  Strahlung  wirkt  nach  alien  Richtungen  des 
Raumes  mit  Ausnahme  der  des  Rohrquerschnittes,  so  dass 
die  Geschwulst  von  innen  heraus  in  toto  bestrahlt  wird. 
Durch  Kontrollversuche  hat  man  sich  mit  Hilfe  des  Chromo- 
radiometers  von  der  Leistung  des  Rohres  vorher  iiberzeugt 
und  gibt  nun  beispielsweise  eine  Dosis  von  ca.  8-10  H  in  einer 
Sitzung.  Urn  das  Rohr  zu  schonen  und  starke  Erhitzung 
zu  vermeiden,  wendet  man  relativ  schwache  Strome  an.  Im 
iibrigen  sorgt  auch  das  stromende  Blut  im  umgebenden  Gewebe 
fur  Abkuhlung  des  Rohres.  Bei  starkerer  Bestrahlung  bildet 
sich  natiirlich  als  Folge  der  intensiven  Bestrahlung  ein  nekrot- 
ischer  Zylinder  im  Gewebe,  speziell  bei  Verwendung  eines 
weichen  Rohres.  Wie  weit  die  Bestrahlungen  auszudehnen 
sind,  hangt  ab  von  der  Grosse  und  Situation  des  Tumors 


DERMATOLOGICAL  CONGRESS  485 

und  muss  die  Bestimmung  dariiber  dem  Verstandnis  und 
der  Erfahrung  des  Rontgentherapeuten  uberlassen  bleiben. 
Unter  Umstanden  miissen  mehrere  Offnungen  fur  das  Rohr 
angelegt  werden.  Bei  kleinen  Driisentumoren,  die  direkt 
unter  der  Haut  zu  fuhlen  sind,  macht  man  nur  einen  Schnitt 
durch  die  Haut  und  schiebt  am  besten  das  schon  erwahnte, 
fur  "subkutane  Bestrahlung"  eigens  angegebene  Rohr  durch, 
denselben  so  ein,  dass  die  nur  nach  einer  Seite  wirkende 
Strahlung  die  Druse  trifft,  die  Haut  aber  geschont  bleibt. 

Man  wird  sich  bald  iiberzeugen,  dass  die  durch  vorstehende 
Methode  der  intratumoralen  Bestrahlung  hervorzubringenden 
Effekte  rascher  auftreten  als  bei  der  fokalen  Bestrahlung,  die 
naturlich  bei  off  en  anliegenden  ulzerierten,  nicht  mehr  von 
Haut  bedeckten  Tumoren  eben falls  angewendet  wird. 

Ich  habe  als  Erster  nachgewiesen,  dass  die  durch  ein 
Aluminiumfenster  aus  dem  Vakuumrohr  nach  aussen  geleiteten 
direkten  "ausseren  Kathodenstrahlen "  eine  Strahlung  dar- 
stellen  welche  den  Effekt  der  Rontgen-  und  Radiumstrahlen 
absolut  an  Starke  ubertrifft  und  ebenso  therapeutisch  fur 
Karzinombehandlung  verwertbar  ist.  Ich  habe  naturlich 
auch  darnach  gestrebt,  einen  Modus  zu  finden,  um  auch  diese 
iiberlegene  Strahlengattung  intratumoral  zu  verwenden  und 
ist  mir  dies  eben  falls  gegluckt.  Interessenten  stehe  ich  gerne 
mit  naheren  Daten  zu  Diensten. 

Vorliegende  Arbeit  soil  lediglich  auf  die  neue  Methode, ' 
die   ich  unbedingt   als   Fortschritt   der  radiotherapeutischen 
Technik  betrachte,  hinweisen  und  Interessenten  veranlassen, 
sie  nachzuprufen. 

Ich  mochte  nun  noch  auf  einige  wichtige  Punkte  hinweisen. 

Durch  die  schone  Arbeit  von  Lomer  (Zur  Frage  der  Heil- 
barkeit  des  Karzinoms;  in  Zeitschr.  f.  Geburtsh.  u.  Gynakol. 
1903,  50.  Bd.,  2.  H.)  wird  der  Gedanke  nahegelegt,  dass  alle 
jene  Momente,  welche  Blutzerfall  im  Gefolge  haben,  wie 
Brandwunden,  schwere  Blutungen,  Vergiftungen  mit  Arsen, 
Kali  chloricum,  Fieber,  langdauernde  Eiterungen,  hamolyt- 
ische  Sera  usw.,  auch  eine  mehr  oder  minder  ausgesprochene 
Einschmelzung  der  Krebstumoren  nach  sich  ziehen. 

Durch  die  Arbeiten  von  Schwarz,  Werner,  Exner,  Heineke, 
Benjamin  u.  a.  ist  bewiesen,  dass  lokale  und  allgemeine  Be- 


4S6  SIXTH  INTERNATIONAL 

strahlungen  mit  Rontgenstrahlen  eine  Alteration  des  Blut- 
korpers  hervorbringen  und  zwar  dahingehend,  dass  beide 
Bestrahlungsweisen  Hyperleukozytose  und  Lymphopenie  zur 
Folge  haben,  dass  als  Folge  der  Bestrahlung  im  Gewebe  ein 
Stoff  auftritt,  dem  gegeniiber  sich  die  polynuklearen  Leuko- 
zyten  chemotaktisch  positiv  verhalten  unter  Auftreten  von 
Cholin,  dass  unter  Bestrahlung  der  Leukozytenbildungs- 
statten  unter  Behinderung  der  Neuproduktion  weisser  Blut- 
korperchen  Leukopenie  ensteht. 

Es  ist  nun  daran  zu  denken,  ob — ganz  abgesehen  von  der 
eventuellen  direkten  Beeinflussung  der  Krebszellen  durch 
die  Bestrahlung — sich  der  Effekt  einer  Rontgenbestrahlung 
auf  karzinomatoses  Gewebe  dadurch  steigern  Hesse,  dass  man 
die  Bestrahlungen  nicht  so  angstlich  allein  auf  den  Tumor 
und  seine  Grenzen  beschrankt,  sondern  indem  man  grossere 
Korperteile  mit  in  den  Bereich  der  Bestrahlung  zieht,  in  der 
Annahme,  dass  die  durch  allgemeine  Bestrahlung  ausgelosten 
hamolytischen  Vorgange  in  ihrer  Ruckwirkung  sich  zu  den 
Effekten  der  lokalen  Bestrahlung  des  Tumors  hinzuaddieren 
mochten.  Ich  fur  meinen  Teil  habe  auf  Grund  einer  kleinen 
Anzahl  von  Fallen  den  Eindruck  gewonnen,  als  ob  tatsachlich 
durch  eine  solche  kombinierte  lokale  und  allgemeine  Bestrah- 
lung ein  rascherer  und  umfassenderer  Gang  der  Absorption 
der  Krebsmassen  stattfande. 

Da  derartige  allgemeine  Bestrahlungen,  vorsichtig  aus- 
gefuhrt,  keine  Hautreaktionen  auslosen,  so  sehe  ich  nicht  ein, 
warum  man  sie  nicht  versuchen  sollte.  Es  ware  vielleicht 
sogar  angezeigt,  die  blutbildenden  Organe  direkt  mitzube- 
strahlen,  weil  moglicherweise  die  durch  hamolytische  Vorgange 
ausgelosten  Blutveranderungen  sich  zu  einer  Art  Serum- 
therapie  des  Karzinoms  gestalten  mogen.  Fiir  das  zuletzt 
Vorgebrachte  habe  ich  naturlich  zunachst  keine  Beweise. 

Ich  mochte  sogar  noch  einen  Schritt  weiter  gehen  und 
die  Hamolyse  durch  innere  und  aussere  Applikation  von  chlor- 
saurem  Kali  unterstutzen  (nach  dem  Vorgang  von  Lomer, 
Burow,  Charcot,  Bergeron,  Leblanc,  Milon,  Cooke,  Michon), 
um  die  Arbeit  der  Rontgenstrahlen  vom  aussen  her  recht 
kraftig  zu  unterstiiszen.  Als  Radiotherapeut  soil  man  nicht 
nur  in  seine  Rontgenstrahlen  verliebt  sein  und  nicht  die 


DERMATOLOGICAL  CONGRESS  487 

Moglichkeit  ausser  acht  lassen,  dass  man  durch  die  Kombina- 
tion  der  Rontgenstrahlenwirkung  mit  anderen  therapeutischen 
Gesichtspunkten  vielleicht  viel  profitieren  kann.  Ich  mochte 
deshalb  darauf  hinweisen,  dass  man  die  durch  zahlreiche 
Beispiele  (Schmidts  Jahrb.  1865,  I,  S.  170)  illustrierte  Be- 
einflussung  von  Karzinomen  durch  die  wahrscheinlich  hamo- 
lytische  Wirkung  (Lomer)  des  chlorsauren  Kali  mit  der 
ebenfalls  anerkannten  der  Radiotherapie  verbinden  kann .  Der 
verniinftige  Kritiker  wird  darin  keine  Bankerotterklarung 
der  Radiotherapie  sehen,  sondern  das  Bedurfnis  des  Praktikers, 
unter  alien  Umstanden,  mit  Verzicht  auf  Prinzipienreiterei, 
nur  das  Wohl  der  armen  Kranken  zu  erstreben. 


X-RAY  BATHS  AND  DERMAMETROPATHISM 

BY   DR.    HERMAN   LAWRENCE,   OF  MELBOURNE,  AUSTRALIA 

X-ray  Baths. — What  I  have  termed  an  X-ray  bath  is  a 
method  of  applying  the  X-rays  so  that  the  skin  of  the  whole 
body  may  be  exposed  to  them  at  one  time.  As  shown  in  the 
photograph  (Plate  xxiv),  there  are  six  tubes,  connected  to  six 
separate  coils,  each  coil  having  its  own  break  and  its  own  pri- 
mary current  supply.  At  the  present  time,  I  often  work  coils 
in  series  and  tubes  in  series — that  is,  I  work  two  coils  with  one 
primary  current,  using  one  break,  and  I  sometimes  work  two  or 
even  three  tubes  in  series  connected  with  a  twenty-inch  coil. 
But  I  have  not  found  tubes  in  series  altogether  satisfactory. 
The  patient  stands  with  the  tubes,  three  upon  either  side,  and  at 
a  distance  of  twenty  inches  from  each  tube.  He  then  has  four 
exposures  of  three  minutes  each,  facing  north  for  first  expos- 
ure, south  for  the  next  exposure,  and  then  east  and  west  for 
the  other  two  exposures.  The  reason  for  this  order  of  exposure 
is  that  the  tubes  must  be  altered  as  regards  distance  from  the 
patient,  for  an  antero-posterior  exposure  as  compared  with 
exposure  to  each  side  of  the  patient.  By  altering  the  position 
of  the  patient  in  this  way,  any  unevenness  of  dosage  of  the 
X-rays  from  the  separate  tubes  is  more  or  less  equalized  as 
regards  their  general  effect  upon  his  body. 


488  SIXTH  INTERNATIONAL 

The  patient  is  undressed  and  wrapped  in  a  white  sheet. 
A  lead  foil  mask  is  used  to  protect  the  head  and  there  is  also 
lead  protection  for  the  genital  organs.  He  should  stand  in 
a  cage  made  of  cane,  and  a  nurse  stands  by  to  rotate  him 
at  the  end  of  each  three  minutes'  exposure.  I  operate  the 
bath  behind  a  lead-lined  stand'  with  crown-glass  window. 
The  nurse  has  similar  apparatus  for  her  protection.  In  chil- 
dren I  use  only  four  tubes.  As  regards  dosage,  I  use  radio- 
meter discs  in  order  to  watch  the  effect  of  the  rays  upon  them 
from  each  tube,  but,  of  course,  I  do  not  in  any  way  give  a  dose 
such  as  we  use  for  depilation  in  ringworm.  I  may  say  that  I 
have  treated  some  five  hundred  cases  of  skin  disease  by  radio- 
therapy, and  I  am  of  the  opinion  that,  where  marked  effects 
by  the  X-rays  are  desired  in  a  short  time  (for  in  Australia 
patients  will  come  hundreds  of  miles  and  cannot  remain  for 
more  than  a  week  or  two),  one  can  get  better  results  by  the 
method  of  giving  several  mild  exposures,  as  compared  with 
the  method  of  giving  a  heavy  dose  and  then  waiting  to  see 
the  result  upon  the  patient's  skin. 

I  am  ready  to  admit  the  former  method  requires  a  good 
deal  of  experience  upon  the  part  of  the  operator,  and  I  would 
not  recommend  anyone  to  try  the  X-ray  bath  exposure  I  am 
now  describing  unless  he  thoroughly  understands  the  danger 
of  an  over-exposure.  One  can  easily  understand  that  a 
generalized  reaction  from  an  over-exposure,  or  from  too 
great  an  accumulation  of  the  X-ray  effect  upon  the  skin,  could 
be  followed  by  a  fatal  result.  I  myself  have  worked  the 
method  up  gradually  from  the  simple  tube.  I  frequently 
use  two  sets  of  two  tubes,  as  in  treating  two  arms  or  two  legs. 
Here  there  is  a  great  saving  of  time,  for  instead  of  giving  four 
exposures  of  ten  minutes  (if  that  be  about  the  time  required 
for  a  certain  dose)  to  each  limb,  the  whole  treatment  can  be 
carried  out  in  eight  minutes  if  the  tubes  are  placed  at  the 
same  distance  as  when  the  single  tube  is  applied. 

I  have  used  the  bath  successfully  in  mycosis  fungoides, 
generalized  eczema  and  psoriasis,  obstinate  urticaria  and 
pruritus.  In  children  when  lichen  urticatus  is  very  trouble- 
some it  has  been  followed  by  quick  relief  from  symptoms. 

I  will  now  briefly  relate  four  cases  treated  by  the  bath. 


DERMATOLOGICAL  CONGRESS  489 

CASE  i. — Girl,  aged  eighteen.  Mother  states  her  daughter 
had  been  to  school  in  Europe  for  two  years;  she  developed  a 
severe  attack  of  eczema  and  was  under  treatment  in  London 
for  six  months.  She  did  not  get  better  and  could  not  remain 
away  from  Australia  any  longer.  On  reaching  Melbourne 
she  was  recommended  to  consult  me  as  to  having  X-ray 
bath  treatment.  When  I  examined  her  she  had  a  bad  ca- 
tarrhal  inflammation  of  the  skin  of  both  arms  and  legs;  her 
face  and  trunk  were  slightly  affected.  I  saw  by  her  pre- 
scriptions that  she  had  had  the  best  of  treatment,  and  I  thought 
in  her  case  I  was  justified  in  using  the  X-ray  bath.  She  had 
three  baths  the  first  two  weeks,  and  then  two  tube  exposures 
for  three  weeks;  by  this  time  the  eczema  was  so  subdued  I 
allowed  her  to  return  home.  Her  recovery  was  complete 
and  there  has  not  been  any  return  of  the  eczema  since. 

CASE  2. — Man,  aged  forty-five.  Psoriasis  for  past  twenty- 
five  years ;  had  been  to  Europe  upon  two  occasions  for  treat- 
ment which  relieved  but  did  not  cure  him.  He  said  he -was 
discouraged  with  the  treatment  which  had  been  employed 
as  the  ointment  spoiled  his  clothes,  and  for  the  past  two  or 
three  years  he  was  content  to  put  up  with  the  psoriasis,  merely 
using  olive  oil  and  baths  to  lessen  the  scaling.  He  was  a 
relative  of  the  girl  just  mentioned,  and  said  he  had  come  to 
know  if  I  thought  the  X-ray  bath  could  be  of  value  to  him. 
I  undertook  the  case,  and  in  six  weeks  he  was  free  of  the 
psoriasis.  He  was  so  pleased  that  he  continued  to  have  an 
X-ray  bath  once  a  month  for  some  time.  However,  in 
spite  of  treatment,  guttate  spots  appeared  occasionally. 
To  these  I  applied  radium.  I  have  five  specimens  and  we 
treated  several  of  these  spots  at  one  time.  My  radium  is  of  high 
radio-activity,  and  fifteen  minutes  was,  in  his  case,  quite  suffi- 
cient exposure  at  a  time.  He  was  so  pleased  with  the  result 
that  he  bought  a  specimen  of  radium  for  himself.  It  is  now 
two  years  since  I  first  treated  him,  and  with  his  specimen 
of  radium,  he  tells  me,  he  keeps  quite  free  from  the  disease. 
No  other  treatment  was  used  during  the  X-ray  bath  treatment. 

CASE  3. — Urticaria.  Sister  of  medical  man,  a  very  bad 
case ;  all  treatment  failed  to  relieve  her,  and  her  health  suffered 
from  broken  rest.  With  X-ray  baths  she  was  relieved  of  her 


490  SIXTH  INTERNATIONAL 

trouble  in  two  weeks,  and  went  on  a  trip  for  her  health,  which 
was  not  good.  I  have  not  heard  whether  she  had  any  relapse 
of  the  urticaria.  No  other  therapy  was  used  during  the  X-ray 
bath  treatment. 

CASE  4. — Mycosis  fungoides.  Treatment  by  X-rays  for 
three  weeks,  interval  of  three  weeks,  and  then  another  treat- 
ment for  two  weeks  by  double  tubes.  Tumors  all  resolved. 
Case  was  only  recently  treated,  so  it  is  too  early  for  relapse 
at  present. 

DERMAMETROPATHISM 

Dermametr apathism  is  a  word  I  have  coined,  and  is  meant 
to  express  a  system  of  measuring  a  disease  of  the  skin.  The 
system  is  based  upon  the  result  produced  upon  the  skin  by 
pressure  with  a  smooth  instrument,  such  as  a  pen-handle. 
The  same  instrument  must  be  used  and  the  same  amount  of 
pressure  applied,  as  the  varying  results  obtainable  in  different 
diseases  are  compared  the  one  with  the  other,  or  the  result 
obtained  upon  the  diseased  part  of  the  skin  is  compared  with 
that  obtained  upon  the  skin  which  is  not  diseased.  Now  if 
the  instrument  used  be  too  rough  or  too  smooth,  or  not  ap- 
plied with  a  somewhat  equal  amount  of  pressure,  the  varying 
results  obtained  as  evident  to  the  eye  could  not  be  made  use  of. 
One  must  compare  the  result  obtained  upon  the  diseased 
portion  of  the  skin  with  that  obtained  upon  the  normal  skin 
as  produced  by  similar  conditions. 

My  attention  was  first  drawn  to  this  subject  some  years 
ago  by  a  patient  stating  that  she  noticed  when  she  scratched 
herself  she  produced  white  lines  upon  the  skin,  whereas  if 
her  sisters  or  brothers  scratched  their  skin  they  produced  red 
lines. 

Her  case  was  one  of  almost  universal  eczema  dating  from 
infancy  with  marked  pruritus  and  velvety  thickening  of  the 
skin,  being  especially  so  upon  the  extensor  aspects  of  the 
limbs. 

I  applied  the  pen-handle  to  her  skin,  which  was  followed 
by  the  production  of  white  lines.  I  then  similarly  examined 
the  skins  of  the  other  members  of  the  family,  two  older  and 


DERMATOLOGICAL  CONGRESS  491 

three  younger  than  herself,  and  in  all  of  them  the  pressure 
with  the  pen-handle  was  followed  by  the  production  of  red  lines 
upon  the  skin. 

I  watched  for  similar  cases  of  eczema  and  in  four  such 
cases,  whose  ages  varied  from  twenty  to  forty-five  years, 
the  same  results  were  obtained  on  the  application  of  pressure 
to  the  skin. 

I  then  noticed,  and  the  patients  themselves  agreed  with 
my  observations,  that  the  white  lines  were  more  markedly 
evident  and  lasted  longer  when  the  disease  was  more 
exaggerated.  I  began  examining  all  varieties  of  cuta- 
neous affections  by  this  method,  which  I  named  "skin  mark- 
ings." In  a  great  number  of  skin  diseases  so  examined,  the 
results  obtained  did  not  appear  to  be  of  any  special  interest ; 
but,  on  the  other  hand,  in  a  certain  number  of  cases  they 
seemed  to  me  to  be  of  considerable  interest,  and  so  I  have 
taken  this  opportunity  of  bringing  this  subject  under  your 
notice.  By  this  method  there  are  seven  distinct  lines  or  marks 
obtainable,  and  it  is  by  observing  the  variability  of  these 
lines,  the  different  combinations  they  enter  into,  and  the  differ- 
ence in  time  that  they  remain  visible  that  one  can  apparently 
make  use  of  them. 

No.  i  line,  or  marking,  is  produced  by  drawing  with  slight 
pressure  a  smoothly  rounded  off  pen-handle  across  the  skin. 
You  will  notice  a  white  line.  Immediate  pressure  line. 

No.  2  line,  or  marking,  is  a  red  line,  which  usually  follows 
in  a  few  seconds  after  No.  i  line.  It  is  about  the  same  width 
as  the  end  of  the  instrument  or  marker  used. 

No.  3  line  is  also  a  red  line,  but  an  exaggerated  one,  being 
two  or  three  times  as  broad  as  the  end  of  the  marker 
applied. 

No.  4  line  is  a  red  line  with  a  white  line  upon  either  side 
of  it. 

No.  5  line  is  a  white  line,  so  that  in  this  case  one  has  two 
white  lines,  No.  i  line  being  followed  by  a  white  line.  It  is  not 
a  raised  line. 

No.  6  line  is  a  raised  line  which  follows  upon  a  red  line, 
so  that  in  this  case,  there  is  a  white  line  followed  by  a  red  line, 
and  then  a  raised  line  is  produced. 


492  SIXTH  INTERNATIONAL 

No.  7  is  also  a  raised  line,  but  it  follows  upon  a  white  line, 
either  No.  i  line  or  No.  5  line. 

These  lines  or  markings  are  usually  much  more  easily 
observed  upon  the  trunk  than  upon  the  limbs. 

Now  as  these  lines  or  markings  vary  as  regards  their  quality, 
and  also  as  regards  the  time  they  last,  I  have  placed  the  +  or 
-  sign  before  the  line  or  marking,  in  order  to  express  whether 
the  line  or  marking  is  greater  or  less  than  the  usual  marking. 
For  instance,  if  you  draw  a  pen-handle  across  the  back  of  the 
hands  when  they  are  red  and  swollen  with  the  cold,  the  white 
lirie  is  very  marked,  and  in  such  a  condition  one  would  call  it 
+  i .  And  as  regards  the  time  the  marks  last  I  have  used  the 
same  signs,  +  or  -,  but  placed  after  the  line.  For  instance 
if  No.  6  line  lasted  for  forty-five  minutes,  then  the  marking 
would  read  6  +.  Here  the  +  is  equal  to  forty-five  minutes. 

What  I  contend  is  that  by  this  method  of  clinical  observation, 
which  I  call  "skin  marking,"  certain  markings  indicate  the 
chronicity  of  certain  diseases  and  give  warning  in  some  cases  of 
the  near  onset  of  a  relapse  of  the  disease;  that  certain  markings 
explain  the  exaggeration  of  the  symptoms  in  some  individuals, 
and  that  probably  suitable  treatment  may  be  worked  out  by  ob- 
serving the  effect  of  the  markings  upon  the  skin. 

Now  for  the  statement  that  certain  markings  explain  the 
exaggeration  of  the  symptoms  in  some  individuals. 

Take  for  instance  persons  troubled  with  acne  vulgaris. 
Why  is  it  that,  in  some  cases,  there  is  very  little  congestion 
or  inflammation  around  the  comedones  or  plugs  of  sebaceous 
matter,  while  in  other  cases  there  is  marked  exudation  and 
papule  formation?  I  contend  that  in  some  cases  it  is  coinci- 
dental with  an  increased  irritability  of  the  tissues  in  the  latter 
subjects,  which  irritability  can  in  some  cases  be  calculated  or 
evidenced  by  this  system  of  skin  markings.  I  have  proved 
this  fact  in  many  cases,  and  will  try  to  explain  what  I  mean. 

Two  girls,  twins,  aged  sixteen  years,  were  treated  by  me 
for  bad  acne  of  the  face.  We  will  call  them  A.  and  B.  Case 
A.  marked  +i,  +3,  and  Case  B.  marked  +i,  +3  +,  +6  +. 
You  notice  that  Case  B.  marks  +  after  3  and  6  +,  in  addition 
to  the  markings  of  Case  A.  The  +  after  3  and  6  represent 
the  increased  irritability  of  the  tissues,  and  is  the  reason 


DERMATOLOGICAL  CONGRESS  493 

why  in  these  two  cases  there  is  so  much  more  disturbance 
around  the  acne  plug  in  Case  B.  And  as  I  will  tell  you  pres- 
ently when  Case  B.  ceased  to  mark  +  after  3  and  6,  then 
the  degree  of  congestion  became  the  same  in  Case  B.  as  in  Case 

A.  In  Case  A.  the  papules  were  not  accompanied  by  so  much 
congestion  and  inflammation  as  in  Case  B.     Case  A.  proved 
far  more  amenable  to  treatment  than  Case  B.     On  removing 
with  an  acne  expressor  the  sebaceous  plugs,  the  skin  remained 
practically  undisturbed  in  Case  A.,  but  in  Case  B.  the  re- 
moval of  the  sebaceous  plug   would  be  followed  by  a  small 
round  lump.     So  that  in  Case  B.,  besides  the  increased  vaso- 
dilatation,  you  had  also  a  determination  of  fluid  around  the 
sebaceous  plug,  which  formed,  of  course,  a  suitable  soil  for 
micro-organisms;  and  this  condition  was  the  cause  of  Case  B. 
having   more    exaggerated    symptoms    and    being    more    in- 
tractable to  treatment  than  Case  A. 

This  difference  in  these  cases  lasted  for  more  than  twelve 
months,  when  I  noticed  Case  B.  showed  much  less  disturbance 
around  the  acne  plugs,  and  also  the  formation  of  small  lumps 
(acne  urticata)  had  ceased  to  be  obtainable,  and  upon  marking 
the  skin  the  mark  was  +i,  +3,  as  in  Case  A.  I  do  not  venture 
an  opinion  upon  the  cause  of  the  increased  irritability  of  the 
tissues,  or  the  reason  for  the  cessation  of  the  production  of 
line  6  +  in  case  B.,  but  I  hold  that  a  certain  marking  in  Case 

B.  coexisted  with  the  exaggeration  of  the  symptoms  in  this  case. 

I  have  several  exaggerated  cases  of  acne  vulgaris  which 
have  line  6,  and  in  some  it  is  limited  to  the  acne  regions.  But 
all  severe  cases  of  acne  vulgaris  do  not  necessarily  have  the 
line  6,  but  if  it  is  not  present,  then  there  is  generally  the  boggy 
condition  of  the  skin  previously  described  or  marked  vaso- 
dilatation,  with  increased  irritability  of  the  sensory  nerves  to 
the  skin. 

Certain  markings  indicate  the  chronicity  and  the  near 
approach  of  a  relapse  of  the  disease. 

What  I  mean  is  this :  that  in  certain  cases  there  are  certain 
markings  which  are  obtainable  as  long  as  the  disease  remains, 
and  more  than  this  that  the  markings  in  some  cases  advise 
the  near  approach  of  an  attack.  The  marking  in  the  case 
I  will  now  relate  is  i,  +5,  that  is,  the  immediate  pressure 


494  SIXTH  INTERNATIONAL 

line  is  i,  and  it  is  presently  followed  by  a  well-marked  white 
line,  which  is  not  a  raised  line;  and  when  the  disease  is  im- 
proving the  line  or  marking  alters  to  i,  —  2,  —  5,  which  means 
the  marking  is  becoming  more  like  the  normal  marking,  1,2. 
The  following  case  illustrates  the  coincidental  presence 
of  the  line  i,  +5,  and  fairly  generalized  eczema  occurring 
during  the  winter  months. 

A.  G.,  male,  aged  seventeen  years,  with  a  history  of  eczema 
of  the  trunk,  arms,  and  face  every  winter  since  infancy.  When 
I  examined  him  in  June  (winter  in  Australia)  he  marked  i, 
+  5  upon  all  parts  of  the  trunk,  face,  and  arms,  with  the 
slightest  attempt  of  vaso-dilatation  upon  the  abdomen.  He 
marked  i,  4  upon  the  thighs,  which  were  not  troubled  with 
eczema.  In  spite  of  treatment  his  eczema  proved  most 
troublesome  during  the  winter  months,  but  as  summer  set  in, 
the  eczema  cleared  up  and  the  markings  gradually  changed 
from  i,  +5  to  i,  —2,  — 5.  I  marked  his  skin  in  January, 
and  he  marked  i ,  —  2  fairly  well  all  over  the  chest,  back,  and 
abdomen,  and  his  eczema  had  all  cleared  up.  In  April  of 
this  year  his  marking  relapsed  to  i ,  +  5 ,  and  within  three  weeks 
the  eczema  again  appeared. 

What  I  would  draw  your  attention  to  more  particularly 
is  this,  that  this  patient  who  more  or  less  had  learned  the  value 
of  the  markings  upon  the  skin  consulted  me  and  reported  that 
his  markings  had  become  worse,  and  supposed  that  a  fresh 
attack  of  eczema  was  imminent,  which  actually  proved  to  be 
correct — that  is  to  say,  in  his  case  a  marking  i,—  2,  —  5  became 
i,  +  5  upon  the  skin  before  the  inflammation  as  far  as  the  eye 
could  discern  had  developed,  and  before  any  symptom  of 
irritation  was  felt.  I  hold  that  this  marking  i,  +5  prognosed 
the  near  onset  of  the  attack  in  this  particular  case.  The 
patient,  of  course,  thought  he  should  have  been  treated  as  soon 
as  what  he  called  the  eczema  marking  appeared,  but  there 
were  no  symptoms  or  evidence  of  the  disease  to  treat.  I 
think  the  marking  in  this  case  is  suggestive  as  regards  the 
etiology  of  this  form  of  eczema. 

As  regards  dermametropathism,  or  measuring  the  disease 


DERMATOLOGICAL  CONGRESS  495 

by  this  method,  I  would  mention  the  following  cases.  A  case 
of  unilateral  hyperidrosis  of  the  face  and  head,  right  side. 
The  patient  had  to  mop  the  right  side  of  his  face  and  head 
continually  as  the  sweat  kept  on  accumulating  upon  these 
parts.  His  marking  upon  the  right  side  of  the  face  was,  i, 
+3  +;  here  the  +  after  3  represented  twenty-five  minutes. 
The  left  side  marked  normally  i,  2.  When  examined  some 
two  months  afterward,  the  sweating  had  become  much  less, 
and  although  he  still  had  No.  3  line,  it  lasted  for  only  ten 
minutes,  and  when  he  gets  well  of  the  hyperidrosis  the  marking 
upon  the  right  side  of  his  face  will  apparently  become  the 
same  as  upon  the  left  side. 

Urticaria  pigmentosa.~In  three  typical  cases  the  mark- 
ing has  been  +1,7  +  upon  the  spots,  and  i,  —  2  upon  the  skin 
between  the  spots.  That  is,  on  marking  the  spots  there  de- 
velops a  well-marked  white  pressure  line,  followed  by  a  raised 
line,  and  upon  the  skin  between  the  spots  a  white  line  is  fol- 
lowed by  an  indistinct  red  one.  In  one  of  my  cases,  which  has 
been  under  observation  for  three  years,  the  child's  condition  has 
considerably  improved,  and  in  this  case  the  marking  has 
likewise  altered  considerably  in  the  direction  of  becoming 
a  normal  one.  That  is,  the  +  after  7  in  this  child  at  three 
years  of  age  was  equal  to  twenty-five  minutes;  whereas  at  six 
years  of  age  the  +  after  7  was  only  five  minutes;  and  the 
amount  of  redness  which  may  be  produced  by  friction  between 
the  spots  has  likewise  markedly  increased. 

Acute  dermatitis  of  the  face  and  hands. — A  man  suffered  from 
this  trouble  whenever  he  worked  in  the  tramway  factory 
sheds,  the  particular  timber  affecting  him  being  blackwood. 
Upon  its  being  sawn  up,  the  dust,  flying  upon  his  hands  and 
face,  would  cause  an  acute  dermatitis  with  much  swelling, 
and  he  would  have  to  leave  off  working.  For  twelve  months 
he  was  always  subject  to  this  dermatitis,  and  the  question 
arose  whether  he  would  not  have  to  change  his  occupation. 
During  all  of  this  time  his  skin  gave  a  raised  line,  urti- 
caria factitia,  both  during  and  between  the  attacks,  when 
it  was  apparently  quite  well.  But,  fortunately,  the  skin 
at  last  ceased  to  give  a  raised  line  or  urticaria  factitia,  when 
the  pen-handle  was  pressed  upon  it,  and  then  the  man  ceased 


496  SIXTH  INTERNATIONAL 

to  suffer  from  his  dermatitis  due  to  the  blackwood — that  is 
to  say,  all  the  time  his  skin  was  in  a  condition  in  which  urticaria 
factitia  could  be  produced  he  was  unable  to  work  in  the  factory 
sheds  without  getting  an  acute  dermatitis  of  the  exposed 
parts;  but  when  the  skin  ceased  to  give  a  raised  line  upon 
being  marked,  then  he  could  work  in  the  blackwood  dust  with 
impunity.  After  being  free  from  this  idiosyncrasy  to  the 
blackwood  dust  for  eight  months,  his  skin  unfortunately  again 
assumed  the  condition  in  which  pressure  upon  it  with  the 
marker  produced  urticaria  factitia,  and  he  once  more  became 
subject  to  the  dermatitis.  1  have  examined  other  cases  in 
which  patients  have  been  especially  prone  to  dermatitis  from 
certain  plants,  as  in  one  case  due  to  the  primula  obconica; 
but  in  this  instance  an  accompanying  condition  of  urticaria 
factitia  was  absent. 

Mumps. — Alteration  of  markings  due  to  mumps.  Two 
children,  whose  markings  had  been  frequently  taken  during 
two  years,  and  in  whom  they  always  remained  the  same, 
showed  complete  alteration  during  the  acute  stage  of  mumps. 

ist  case:  Boy,  aged  twelve,  markings  always  a  white  line 
followed  by  a  red  line,  1,2.  When  he  developed  mumps  his 
marking  was  a  well  defined  urticaria  factitia,  a  line  raised  as 
high  as  a  small  pen-handle;  as  the  disease  disappeared  his 
marking  returned  to  its  usual  or  normal  condition. 

2d  case:  Girl,  aged  sixteen,  markings  always  i,  2  upon  the 
trunk,  arms,  and  thighs ;  but  upon  the  face  the  marking  was 
i,  —5.  That  is,  she  marked  normally  upon  the  body  and 
limbs,  but  over  the  skin  of  her  face  there  was  a  white  line 
followed  by  a  feeble  white  line.  During  an  attack  of  mumps 
urticaria  factitia  was  produced  upon  the  trunk  and  limbs  where 
she  had  had  the  normal  marking,  but  upon  the  face  the  mark- 
ing i,  —  5  changed  to  i,  +  5  +,  so  that  upon  the  face  she  gave 
a  well-marked  white  line  lasting  some  minutes.  I  think  in 
this  case  the  exaggeration  of  the  abnormal  marking  upon  the 
face,  instead  of  a  tendency  to  the  condition  of  urticaria  fac- 
titia as  upon  the  trunk,  under  the  influence  of  mumps,  is 
difficult  to  understand. 

Sderoderma;  Morphcea  Patches. — In  several  cases  the 
marking  has  been  i,  5  over  the  patch,  and  i,  2  over  the  skin 


PLATE  XXIV.— To  Illustrate  Dr.  Herman  Lawrence's  Article. 


DERMATOLOGICAL  CONGRESS  497 

not  affected.  That  is,  there  has-been  a  white  line  on  pressure 
followed  by  a  white  line,  where  the  skin  was  affected  by  the 
disease,  and  the  skin  beyond  the  patch  was  not  altered  from 
the  patient's  usual  marking.  This  does  not  occur  in  leuko- 
derma,  where  the  marking  over  the  leukodermic  patch  is 
always  the  same  as  the  marking  beyond  the  patch.  Of  course 
one  would  not  expect  any  alteration  in  leukoderma.  The 
following  case  illustrates  my  method:  Patient  with  sclero- 
dermic  patches  of  only  a  few  months'  duration,  situated  upon 
the  back  and  chest.  Upon  marking  the  skin  over  the  affected 
areas  there  was  a  white  line  followed  by  a  white  line.  Just 
immediately  beyond  the  patch  there  was  a  white  line  fol- 
lowed by  a  faint  red  one,  which  later  on  became  a  white  line 
and  upon  the  healthy  skin  the  marking  was  a  white  line 
followed  by  a  red  one.  In  this  patient  by  taking  the  autogram 
in  full,  and  comparing  it  with  the  autogram  at  the  patient's 
next  visit,  after  an  interval  of  four  weeks,  I  was  able  to  answer 
the  question  patients  frequently  ask — that  is:  Is  there  an 
improvement  or  not  in  the  skin  troubles  ?  As  far  as  one  could 
see,  or  feel,  there  was  not  any  appreciable  alteration  in  this 
patient's  cutaneous  affection;  but  on  taking  the  autogram 
in  detail,  I  was  able  to  form  the  opinion  that  the  condition 
was  getting  worse  instead  of  better,  and  this  prognosis  was 
supported  after  another  two  months'  interval,  when  the  spread 
of  the  sclerodermic  patches  had  become  quite  apparent  to  the 
sight  and  touch.  The  patient  then  remained  in  town  and  with 
a  course  of  massage  and  other  treatment,  the  autogram  im- 
proved, and  was  followed  by  evident  improvement  in  the 
sclerodermic  patches.  The  autograms  read  as  follows: 
First  visit  (October) : 

i  (8-10  sec.),  +  5  (  +  =10  min.)  over  patch. 

i  (3-5  sec.),  —  2  (5  sec.)  —  5  (lasting  3  min.)  just  beyond 
patch. 

i  (10-15  sec-)>  2  (lasting  10  min.),  general  skin  marking. 
Second  visit  (November) : 

i  (5-8),   +  5  (  +   =12  min.),  over  patch. 

i  (2-5  sec.), -2  (3  =5  sec.)  =  5  (6 min.)  just  beyond  patch. 

i  (10-15  sec-).  2  (lasting  10  min.)  general  skin  marking. 
Third  visit  (January) : 


498  SIXTH  INTERNATIONAL 

i  (5-8  sec.),  +  5  (  +  =  15  min.)  over  what  is  now  a  much 

larger  patch  of  scleroderma. 
i  (3-5  sec.),  —  2  (4-5  sec.),  —  5  lasting  4  min.,  over  the 

skin  surrounding  new  patch, 
i   (10-12  sec.),  2   (lasting  about  10  min.),  general  skin 

marking. 

In  this  patient  the  patches  were  situated  upon  the  trunk 
of  the  body  and  of  recent  formation.  In  several  chronic 
cases  of  scleroderma  I  have  not  been  able  to  obtain  markings 
as  in  the  case  just  related,  beyond  the  white  line  followed  by 
a  white  line  over  the  diseased  areas,  i,  5.  In  the  case  of 
patient  just  described  she  has  recovered  from  her  skin  trouble 
and  the  skin  marks  practically  normal  all  over.  That  is: 

i  (10-12),  2  (lasting  about  10  min.)  over  the  back  and 
chest. 


ROENTGEN  RAY  IN  EPITHELIOMA.   REPORT 

OF  A  SERIES  OF  CASES  TREATED  MORE 

THAN  THREE  YEARS  AGO 

BY  DR.  WILLIAM  ALLEN  PUSEY,  OF  CHICAGO 

No  one  doubts  that  epitheliomata  can  be  healed  with 
X-rays.  The  statement,  however,  is  frequently  made  that 
the  results  are  not  as  permanent  as  when  the  lesions  are 
radically  destroyed  by  other  methods  of  treatment.  This 
is  an  important  matter  to  settle,  and  we  are  now  nearing  the 
time  when  the  permanency  of  the  result  can  be  established. 
I  desire,  therefore,  to  report  the  results  in  my  series  of  epithe- 
liomata treated  with  X-rays  more  than  three  years  previous 
to  July,  1907. 

The  number  of  cases  is  too  large  to  recite  each  case  in  detail, 
but  the  results  can  be  summarized  quickly.  The  details  of  some 
of  the  cases  also  are  indicated  by  the  photographs  presented  here- 
with, (Plates  xxv-xxviii),  all  of  them  in  pairs,  showing  the  orig- 
inal lesion  and  the  result  after  three  or  more  years.  Lack  of 
space  prevents  the  publication  of  the  photographs  of  about  thirty 
additional  cases.  I  have  confined  my  consideration  to  epithe- 


DERMATOLOGICAL  CONGRESS  499 

liomata.  I  have  not  included  in  my  list  epitheliomata  which 
at  the  time  of  beginning  treatment  were  complicated  by 
demonstrable  carcinoma  in  the  neighboring  glands.  I  have 
thus  excluded  a  few  hopeless  cases  of  epithelioma  of  the  penis 
with  metastatic  complications,  and  numerous  cases  of  car- 
cinoma of  the  neck  following  epithelioma  about  the  face  and 
mouth.  I  have,  however,  excluded  no  case  in  which  glandular 
metastases  developed  after  treatment  was  begun;  fortunately, 
I  had  no  such  accident.  I  have  also  not  excluded  any  cases 
where  the  spread  of  the  disease  has  been  by  continuity.  The 
list,  therefore,  includes  many  hopeless  cases  in  which  there  had 
been  wide  involvement  of  the  orbit,  other  cases  with  deep 
destruction  of  the  tissues  of  the  face  from  the  spread  of  lesions 
originally  involving  the  nose  only,  and  other  extensive  and 
very  destructive  cases.  I  may  also  say  that  in  accepting  the 
cases  no  effort  was  made  at  selection;  the  most  hopeless  ones 
have  been  treated  regardless  of  a  record  whenever  there  was 
the  remotest  possibility  of  giving  the  patients  any  sort  of 
benefit. 

The  total  number  of  epitheliomata  in  this  list  which  I 
treated  with  X-rays  more  than  three  years  ago  is  one  hundred 
and  nineteen.  Of  these  cases  I  have  been  unable  to  obtain 
the  subsequent  histories  of  only  eight;  of  these  eight,  five 
I  think,  should  have  been  successes  and  three  failures,  but, 
throwing  the  entire  number  out  of  consideration,  it  leaves 
one  hundred  and  eleven  patients  treated  more  than  three  years 
ago,  whose  histories  up  to  July  of  this  year  are  known. 

Of  these  one  hundred  and  eleven  patients  eighty  either 
remain  well  to-day,  have  died  without  recurrence  of  epithe- 
lioma, or  remained  well  more  than  three  years  after  a  healthy 
scar  was  produced,  but  can  not  now  be  located.  As  a  matter 
of  fact,  sixty-six  of  these  eighty  patients  were  living  with 
healthy  scars  in  April  last.  Six  were  living  without  recur- 
rence at  least  three  years  after  they  finished  treatment.  Eight 
of  them  are  dead;  two  died  from  pneumonia,  and  one  patient 
each  from  acute  leukaemia,  apoplexy,  nephritis,  heart  dis- 
ease, acute  bowel  trouble,  and  carcinoma  of  the  uterus,  the 
last  mentioned  having  symptoms  before  the  treatment  of 
the  lesion  on  her  face  was  begun.  This  patient  died  about  a 


500  SIXTH  INTERNATIONAL 

year  after  the  lesion  on  her  face  healed,  and  she  was  the  only 
one  who  died  within  a  short  time  after  the  treatment  of  her 
epithelioma.  Two  other  patients  who  are  now  dead  lived 
from  one  and  one-half  to  three  and  one-half  years.  Omitting 
these  eight  patients  who  died  from  other  diseases,  one  patient 
has  been  well  over  six  years,  eleven  patients  are  well  over  five 
years,  twenty-two  over  four  years,  thirty-two  over  three 
years,  and  six  were  well  more  than  three  years  after  treatment, 
but  whether  they  are  now  living  I  do  not  know. 

The  diagnosis  in  the  cases  is,  I  believe,  beyond  question. 
In  all  of  my  earlier  cases  the  diagnosis  was  confirmed  by 
microscopic  examination.  In  the  later  cases  microscopic 
examinations  were  made  when  there  was  any  possible  room 
for  doubt.  The  unmistakable  character  of  the  lesions  and 
the  variety  of  the  lesions  treated  are  evident  to  the  eye  in 
almost  all  of  the  photographs  shown.  They  varied  from 
the  most  minute  epitheliomata,  about  the  size  of  a  small  pea, 
to  lesions  above  the  size  of  a  hand.  Many  of  the  worst  cases 
were  primary  as  regards  operation,  but  of  the  eighty  success- 
ful ones  forty-one  were  primary  and  thirty-nine  were  cases 
which  had  recurred  after  previous  radical  treatment,  usually 
operation. 

For  the  purpose  of  further  analysis  I  have  divided  all  of 
the  cases  into  the  following  four  groups:  (i)  Successful,  eighty 
cases;  (2)  practically  successful,  two  cases;  (3)  distinctly 
benefited,  seventeen  cases;  (4)  failures,  twelve  cases;  total, 
one  hundred  and  eleven  cases. 

PRACTICALLY  SUCCESSFUL 

In  the  group  of  practically  successful  cases  are  included 
two  cases.  The  first  case  was  a  large  epithelioma  of  the 
shoulder. 

This  patient  had  had  for  twenty  years  a  rodent  ulcer, 
which  at  one  time  had  reached  an  enormous  extent,  involving 
at  least  a  square  foot  of  the  shoulder  and  back.  Under 
persistent  treatment,  extending  over  years,  in  the  hands  of  the 
most  competent  men,  it  had  been  reduced  in  size  to  about  that 
of  the  palm  of  the  hand,  but  it  had  never  been  healed.  This 


DERMATOLOGICAL  CONGRESS  SQI 

was  the  first  case  that  I  treated  with  the  X-rays,  and  the 
treatment  was  undertaken  because  the  case  was  regarded  as 
hopeless. 

A  symptomatic  cure  was  obtained  in  May,  1901.  Fifteen 
months  after  the  disappearance  of  her  epithelioma,  this  pa- 
tient, a  very  old  woman,  received  an  injury  from  a  fall  from 
which  she  was  compelled  to  go  to  bed,  and  in  a  few  days  died 
from  pneumonia.  At  the  time  of  her  death  there  was  no 
evidence  of  recurrence,  except  a  point  on  her  shoulder,  which 
looked  suspicious.  I  was  able  to  obtain  the  skin  from  this 
shoulder,  and  it  showed  healthy  scar  tissue,  except  at  this 
suspicious  point,  where  I  found  an  epitheliomatous  mass  the 
size  of  half  a  wheat  grain.  This  could  have  been  destroyed 
readily  by  X-rays  or  a  caustic  or  other  destructive  agent. 

The  second  case  was  epithelioma  involving  the  entire 
concha  and  the  outer  half  of  the  external  auditory  canal. 
A  superficial  ulceration,  the  size  of  a  dime,  has  never  disap- 
peared in  this  case,  and  it  is,  I  believe,  an  X-ray  burn  and  not 
an  epithelioma.  It  showed  no  tendency  to  grow  when  I 
last  saw  the  patient  a  year  ago.  In  this  case  the  lesion  had 
been  converted  into  a  trivial  ulcer  with  no  tendency  to  spread, 
and  the  improvement  had  persisted  for  over  four  years.  This 
case  also  was  an  epithelioma  recurrent  after  operation. 

DISTINCTLY  BENEFITED 

Seventeen  cases  are  classed  as  having  been  distinctly 
benefited.  The  improvement  in  each  of  these  cases  con- 
sisted in  checking  the  course  of  the  disease  for  a  year  or  more, 
except  in  the  case  of  a  man  over  eighty,  who  died  within  the 
year,  and  in  prolonging  the  patient's  life,  in  comfort,  for  at 
least  that  length  of  time.  Every  one  of  the  cases  was  an 
epithelioma  which  had  recurred  after  previous  operation,  and 
practically  all  were  hopeless  of  other  relief.  Seven  of  these 
cases  were  epitheliomata  which  had  begun  at  the  inner  canthus 
and  had  spread  into  the  orbit  and  on  to  the  nose.  In  four 
of  these  the  disease  had  extended  so  far  into  the  orbit  that  the 
eye  had  been  destroyed;  in  two  the  bones  of  the  ridge  of 
the  nose  were  deeply  involved,  and  the  orbit  infiltrated  to  the 


5o2  SIXTH  INTERNATIONAL 

point  where  operation  was  regarded  by  surgeons  who  referred 
the  cases  as  impractical;  in  one  the  disease  had  involved  the 
orbit  and  the  adjacent  bone  to  the  point  where  the  eye  was 
fixed  in  the  carcinomatous  tissue.  In  this  case  the  patient 
had  only  the  one  eye,  the  other  having  been  lost  in  childhood, 
so  that  checking  the  course  of  the  disease  was  of  vital  benefit. 
This  patient  came  under  treatment  in  June,  1903;  the  disease 
was  held  in  check  sufficiently  for  his  eye  to  remain  useful  up 
to  December,  1906,  over  three  years;  since  that  time  the  eye 
has  been  destroyed. 

Four  of  the  seventeen  cases  were  epitheliomata,  the  size 
of  a  large  coin,  involving  the  temple  and  the  outer  canthus  of 
the  eye  and  spreading  into  the  orbital  tissue.  In  each 
of  these  cases  the  external  lesion  was  healed.  In  one  case 
the  disease  recurred  on  the  temple  within  a  year.  A  radical 
operation  was  attempted  by  a  surgeon  and  the  patient  died 
in  a  few  days  from  aspiration  pneumonia.  In  the  second 
case  a  large  external  epithelioma  was  made  to  disappear  almost 
completely,  and  extension  was  checked  for  a  year  and  a  half, 
until  the  patient's  death  from  chronic  spinal  disease.  The 
two  other  patients  are  still  living.  One  is  a  very  feeble  old 
man  whose  external  lesion  was  healed  in  August,  1903.  Two 
years  later  this  had  not  again  ulcerated,  but  I  learn  that  it 
has  since  broken  down.  The  other  patient  was  treated  in 
July,  1903.  The  lesion  on  the  temple  was  converted  into  a 
healthy  scar,  but  the  intra-orbital  mass  did  not  disappear. 
The  patient  is  still  living,  but  he  has  become  an  Eddyite  and 
I  cannot  learn  the  present  condition. 

Case  12  of  this  group  is  an  epithelioma  of  twenty  years' 
duration,  recurrent  after  numerous  operations,  and  involving 
both  alae  nasi  and  the  adjacent  portions  of  the  cheeks.  This 
patient  came  under  treatment  in  April,  1901.  She  was  symp- 
tomatically  cured  within  a  few  months,  except  for  two  minute 
suspicious  nodules  near  the  nose,  one  on  the  right  side  of  the 
face,  the  other  on  the  left.  The  one  on  the  right  side  of  the 
face  was  excised  one  year  later,  and  the  disease  has  not  re- 
curred on  that  side.  The  suspicious  nodule  on  the  left  side 
of  the  face  remained  quiet  for  five  years ;  within  the  last  year 
however,  it  has  grown  somewhat,  and  in  July,  1907,  this  was 


DERMATOLOGICAL  CONGRESS  503 

removed  by  operation.  This  patient  was  practically  well 
for  five  years,  but  has  a  small  lesion  on  the  left  ala  nasi  now. 

Cases  13  and  14  in  this  group  were  very  extensive  epithe- 
liomata  which  had  entirely  resisted  other  forms  of  treatment. 
Case  13  was  an  epithelioma,  in  an  old  woman,  involving  almost 
the  entire  forehead,  the  upper  and  lower  lids  and  the  eye  on 
the  left  side,  the  upper  lid  of  the  other  eye,  and  the  upper 
half  of  the  nose.  This  patient  came  under  treatment  in  May, 
1902.  The  lesions  were  entirely  healed  for  over  four  years. 
In  1906,  four  and  one-half  years  after  the  case  came  under 
treatment,  an  ulcer  developed  in  the  centre  of  the  forehead. 
This  patient  is  still  under  my  care  with  an  ulcer  in  the  centre 
of  the  forehead,  which  has  entirely  destroyed  the  frontal  bone 
over  an  area  the  size  of  a  silver  dollar,  but  under  the  X-ray 
exposure  has  remained  quiescent  for  months.  In  this  case 
the  patient  was  symptomatically  relieved  of  a  hideous  epithe- 
lioma for  four  and  one-half  years,  and  her  life  has  been  pro- 
longed in  comparative  comfort  to  the  present  time. 

Case  14  was  an  epithelioma  larger  than  the  hand  and  very 
deep,  situated  over  the  middle  of  the  spine,  in  an  old  woman. 
The  patient  came  under  treatment  in  June,  1904,  and  the 
lesion  was  reduced  to  a  painless,  apparently  benign,  ulcer 
the  size  of  three  ringers.  This  improvement  was  maintained 
in  the  summer  of  1906,  when  the  last  report  was  received. 

Case  15  was  an  epithelioma  of  the  upper  lip,  which  had 
perforated  the  lip  and  involved  the  septum  nasi,  in  a  woman 
over  90  years  old  and  extremely  feeble.  In  this  case  complete 
healing  was  obtained,  which  persisted  for  about  a  year.  The 
disease  then  recurred  without  further  treatment,  but  under 
treatment  was  held  in  check  until  the  patient's  death  from 
natural  causes  two  years  after  coming  under  treatment. 

Case  1 6  was  one  of  deep-seated  epithelioma,  the  size  of  a 
silver  dollar,  in  the  centre  of  the  cheek,  in  a  very  old  woman. 
This  patient  came  under  treatment  in  April,  1904.  The 
lesion  was  made  to  disappear,  except  for  some  subcutaneous 
induration.  Regrowth  did  not  begin  until  a  year  later,  but 
when  the  tumor  recurred  it  caused  the  patient's  death. 

Case  1 7  was  an  epithelioma  of  the  lower  eyelid  which  came 
under  treatment  in  December,  1903.  Healing  of  the  lesion 


504  SIXTH  INTERNATIONAL 

was  produced,  but  later  a  recurrence  developed  for  which 
the  patient  was  treated  by  another  physician  with  the  X-rays. 
At  the  present  time  he  remains  well,  nearly  four  years  since 
he  came  under  my  care.  This  case  is  actually  a  success,  but 
not  mine. 

Although  these  cases  can  not  be  classed  as  technically 
successful,  the  improvement  obtained  in  many  of  them  is, 
I  believe,  one  of  the  strongest  illustrations  of  the  usefulness 
of  X-rays.  The  cases,  as  a  whole,  represent  a  class  which  is 
utterly  hopeless,  with  extension  of  the  disease  so  widespread 
that  complete  removal  by  surgical  measures  is  practically 
impossible.  To  take  such  patients  and  improve  their  lesions 
to  the  point  where  life  is  bearable  or  they  are  symptomatically 
relieved,  is  to  do  what  can  be  done  in  no  other  way. 

FAILURES 

Twelve  cases  are  classed  as  failures.  Nine  of  these  were 
recurrent  after  previous  operation  and  three  were  primary. 
Eight  of  the  twelve  cases  were  hopeless  from  the  standpoint 
of  surgical  interference.  Five  of  these  eight  were  epithe- 
liomata  which  had  spread  deeply  into  the  orbit.  Two  were 
epitheliomata  which  had  completely  destroyed  the  nose  and 
had  extended  deeply  into  the  bones  of  the  face.  One  case 
was  an  epithelioma  which  had  destroyed  the  lower  half  of 
the  ear  and  had  invaded  the  neck.  Seven  of  these  eight 
patients  were  treated  for  but  a  short  time  and  really  should 
not  be  considered.  The  eighth  case,  a  very  extensive  epithe- 
lioma which  had  destroyed  the  nose,  was  kept  under  treatment 
until  the  patient's  death  without  appreciable  improvement 
from  the  use  of  X-rays.  The  ninth  case  of  the  twelve  failures 
was  an  epithelioma  in  a  man,  aged  60,  which  had  destroyed 
the  lower  eyelid  but  did  not  show  palpable  evidences  of  in- 
volvement of  the  orbit;  healing  was  produced  in  this  case 
and  the  patient  then  abandoned  treatment.  Two  years  later 
I  was  informed  that  there  was  evidence  of  recurrence.  The 
tenth  case  was  a  large  epithelioma  of  the  back  of  the  hand 
in  a  man  aged  68,  referred  to  me  by  a  surgeon.  .Temporary 
healing  was  produced,  recurrence  took  place  in  the  course 


PLATE  XXV.— To  Illustrate  Dr.  W.  A  Pusev's  Article. 


FIG.  1. — Epitheliomata,  lower  lip  and  lower 
eyelid,  treated  August,  1902. 


FIG.  2  —Photograph  of  patient 

shown  in  Fig.  1,  August, 

1907,  after  five  years. 


PLATE  XXVI.— To  Illustrate  Dr.  W.  A.,Pusey's  Article. 


FIG.  3.— Epithelioma  of  lip,  March,  1903. 


Fio.  4. — Photograph  of  patient  shown  in  Fig.  3,  with 
healthy  scar,  April,  1907. 


PLATE  XXVII.— To  Illustrate  Dr.  W.  A.  Pusey's  Article. 


FIG.  5. — Epithelioma,  April,  1903. 


FIG.  6. — Photograph  of  patient  shown  in 

Fig.  •">.  with  healthy  scar,  April, 

1907,  after  four  years. 


PLATE  XXVIII.— To  Illustrate  Dr.  W.  A.  Pusey's  Article. 


FIG.  7. — Epithelioma,  April,  1903. 


FiO.  8. — Photograph  of  patient  shown 

in  Fig.  7,  May,  1907.  healthy 

scar  for  four  yearn. 


505 

of  eighteen  months,  and  without  further  treatment  at  my 
hands  the  carcinoma  progressed  and  finally  caused  his  death. 
Case  IT  was  a  recurrent,  superficial  epithelioma  of  the  forehead 
which  was  healed,  but  later  there  was  a  recurrence,  for  which 
the  patient  was  treated  by  another  physician  and  she  is, 
I  believe,  now  well,  five  years  after  I  treated  her.  Case  12 
was  a  recurrent  epithelioma  of  the  side  of  the  nose  and  inner 
canthus,  which  I  healed  six  years  ago.  In  the  last  few  months 
she  appeared  with  a  small  epithelioma  on  the  bridge  of  the 
nose  near  the  site  of  the  original  lesion.  The  new  lesion  has 
promptly  yielded  to  X-rays. 

Cases  9,  10,  n,  and  12  in  this  group  might  be  classed  as 
distinctly  benefited,  but  in  view  of  the  fact  that  they  were 
cases  which  might  have  been  cured,  they  are  classed  as  failures. 
Amputation  of  the  hand,  I  believe,  would  have  saved  Case  10. 
Case  9  would,  I  believe,  judging  from  my  experience  in  orbital 
carcinoma,  have  been  a  surgical  failure.  It  had  recurred 
already  after  operation.  Case  n,  I  believe,  and  Case  12  are 
at  present  well  and  are  not  actually  failures. 

SUMMARY 

Of  the  thirty-one  cases  which  are  classed  as  not  entirely 
successful,  twenty-eight  were  cases  which  had  failed  of  relief 
under  other  forms  of  treatment;  only  three  were  primary 
cases.  These  three  cases  were  all  in  the  group  of  failures; 
they  were  all  carcinomata  involving  the  orbit  and  were  in- 
operable. There  are  in  this  entire  list  of  thirty-one  cases 
not  successful  only  five  cases  in  which,  in  my  opinion,  there 
was  any  hope  of  cure  by  other  methods  of  treatment.  All 
of  these  five  cases  had  previously  been  treated  surgically  and 
all  were  referred  to  me  by  surgeons.  One  of  these  five  cases, 
Case  2,  in  the  practically  successful  group  was  an  epithelioma 
involving  the  external  auditory  canal.  The  other  four  were 
Cases  9,  10,  n,  and  12  among  the  failures  which  have  been 
considered  in  the  preceding  paragraph. 

There  is,  however,  room  for  quibbling  about  all  of  the 
cases  which  are  not  radically  successful.  Counting  then  the 
thirty-one  cases  which  were  not  radically  cured  as  failures, 


5o6  SIXTH  INTERNATIONAL 

there  remain  eighty  successful  cases  in  a  list  of  one  hundred 
and  eleven  successive  cases  of  epithelioma  treated  more  than 
three  years  ago,  a  showing  of  seventy-two  per  cent,  of  suc- 
cessful results.  This  record  will,  I  believe,  bear  comparison 
with  that  of  any  similar  group  of  cases  treated  by  any  other 
method. 


REPORT  OF  EIGHT  HUNDRED  DERMATOLOGICAL 
CASES  TREATED  WITH  X-RAY  AND  HIGH- 
FREQUENCY  CURRENTS  AT  THE  MOUNT 
SINAI  HOSPITAL  (Dr.  Lustgarten's  Clinic) 

BY  DR.  SAMUEL  STERN,  OF  NEW  YORK 

The  subject  of  "Radiotherapy"  is  one  that  is  of  extreme 
interest  to  all  dermatologists.  It  is  one  of  the  youngest 
branches  of  medical  science,  and  for  the  short  period  of  its 
existence  has  created  more  dispute  and  occupied  a  larger  part 
of  our  medical  literature  than  probably  any  other  branch  of 
medicine. 

It  has  practically  divided  dermatologists  into  a  number 
of  factions,  running  all  the  way  from  the  ultra  radicals,  who 
advocate  its  use  in  every  form  of  skin  disease,  to  the  ultra 
conservatives  who  almost  entirely  condemn  it. 

The  only  way  to  determine  which  faction  is  correct  is  by 
continued  experiments  and  the  collecting  of  carefully  com- 
piled statistics  as  reported  by  reliable  observers.  This  is  a 
very  difficult  matter,  as  we  often  find  very  much  exaggerated, 
and  occasionally  absolutely  ridiculous  claims  published  in 
our  medical  literature  by  men  who  rush  into  print  with  all 
sorts  of  wonderful  cures  without  waiting  to  see  whether  these 
cures  will  stand  the  test  of  time  or  are  merely  temporary 
improvements. 

Often  they  are  misguided  themselves,  only  to  discover 
this  fact  too  late  to  retract  their  claims,  and,  unfortunately, 
they  do  not  take  the  trouble  or  do  not  think  it  of  sufficient 
importance  to  amend  their  reports  and  acknowledge  their 
error.  Probably  some  are  not  misguided  as  much  as  they 


DERMATOLOGICAL  CONGRESS  507 

are  misleading,  to  satisfy  their  craving  for  notoriety.  Others 
do  not  appreciate  the  fact  that  their  failures  may  be  due  to 
faulty  technique  or  imperfect  apparatus.  In  a  number  of  in- 
stances, again,  miracles  are  probably  performed  as  the  result  of 
wrong  diagnoses.  In  fact,  there  are  so  many  things  to  be  con- 
sidered in  determining  the  respective  standing  of  radiotherapy 
in  dermatology  that  the  task  is  indeed  a  very  difficult  one. 

That  this  standing  is  a  very  important  one  is  beyond 
question.  We  are  to-day  in  a  position — thanks  to  the  aid 
of  radiotherapy — to  benefit  and  even  cure  a  large  number 
of  chronic  cases,  a  number  of  which,  such  as  mycosis  fungoides, 
rhinoscleroma,  etc.,  were  not  so  very  long  ago  regarded  as 
practically  hopeless. 

The  manner  in  which  the  X-ray  does  its  work  is  still  in 
dispute.  Its  ultimate  action  is  that  of  a  destructive  agent. 
It  will  destroy  animal  tissue,  and  probably  the  fundamental 
basis  of  its  beneficial  effects  in  dermatology  is  due  to  the  fact 
that  diseased  tissue  has  a  much  lower  vitality  and  is  more 
rapidly  destroyed  than  healthy  tissue.  The  parts  of  the 
tissue  primarily  affected  are-  the  cellular  elements,  which 
undergo  a  slow  degeneration ;  while  the  connective  and  elastic 
tissues  are  only  affected  as  the  result  of  this  cell  disintegration. 
The  bactericidal  effects  of  the  X-ray  are  probably  worthy 
of  very  little  consideration. 

Sir  Oliver  Lodge1  considers  that  the  destructive  effects  of 
the  rays  are  secondary,  and  are  due  to  ultra-violet  light  and 
to  the  chemical  or  ionizing  action  of  the  rays  upon  the  tissues 
or  upon  air  in  immediate  contact  with  the  exposed  surface. 
That  is,  the  rays  have  an  oxidizing  action. 

Bordier2  showed  that  the  X-rays  have  an  effect  on  the 
phenomena  of  osmosis,  and  that  the  consequent  interference 
with  the  molecular  changes  is  followed  by  disturbances  of 
nutrition  and  inflammation. 

Holzknecht3  divides  the  various  tissues  according  to  their 
susceptibility  to  the  X-ray,  in  the  following  order: 

«  Bristol  Medico-Chirurgical  Journal,  vol.  205. 

2  Med.  Electrol.  and  Radiol.,  vii,  72. 

3  Arch,  d'  Electric.  Med.,  Jan.  10-25,  I9°5  (Abstract  in  Med.  Electrol.  and 
Radiol.,  vi,  49). 


So8  SIXTH  INTERNATIONAL 

1.  Very  sensitive:  Lymphoid  tissue,  the  skin  modified  by 
psoriasis  and  mycosis  fungoides. 

2.  Sensitive:  Skin  modified  by  inflammation — acne,  sy- 
cosis, lupus,  and  epitheliomatous  tissue. 

3.  Moderately    sensitive:    Healthy    epidermis    and    its 
appendages. 

4.  Very  little  sensitive :  Connective  tissue,  vessels,  et  cetera. 
I  think  we  may  add,  as  recent  developments  have  shown, 

spermatozoa  and  rhinoscleroma  to  the  category  of  very  sensi- 
tive, and  the  various  forms  of  eczema  to  the  sensitive  class. 

The  manner  in  which  the  high-frequency  spark  does  its 
work  is  of  an  entirely  different  nature.  Given  in  mild  doses 
and  through  various  forms  of  vacuum  tubes,  it  has  a  gently- 
stimulating,  antipruritic  action;  and  in  stronger  doses,  es- 
pecially if  applied  through  carbon  or  metallic  electrodes,  it 
has  a  cauterant,  destructive  action,  not  unlike  that  of  a  thermo- 
cautery,  but  much  more  easily  managed  and  the  dosage  far 
better  regulated. 

At  the  Mt.  Sinai  Hospital  of  this  city  (Dr.  Lustgarten's 
Clinic)  we  have  treated  during  the  past  three  years  about  eight 
hundred  dermatological  cases  with  X-rays  and  high-frequency 
currents.  The  object  of  this  paper  is  to  give  a  form  of  statistical 
report  as  to  the  results  accomplished  in  these  cases.  Time  does 
not  permit  me  to  go  into  any  lengthy  detail,  so  I  will  divide 
them  [under  different  headings  and  briefly  report  upon  them. 

Epithelioma.  The  longer  we  treat  epithelioma  with  ra- 
diant energy,  the  more  we  realize  that  our  success  depends 
a  great  deal  upon  the  proper  choice  of  cases.  The  man  who 
will  depend  upon  this  form  of  treatment  as  a  matter  of  routine 
is  doomed  to  a  great  many  disappointments.  There  is  no  ques- 
tion as  to  the  value  of  the  method  in  suitable  cases,  but  there 
is  also  no  question  as  to  its  failure  in  improperly  chosen  ones. 
It  is  very  hard  to  lay  down  any  fixed  or  definite  rules  as  to 
the  choice  of  cases.  Experience  is  the  most  important  factor. 
As  a  general  rule,  it  might  be  said  that  the  lesions  best  adapted 
for  radiotherapy  are  those  which  are  situated  on  the  surface 
of  the  epidermis.  Deeper-seated,  nodular  epitheliomas  are 
best  treated  by  other  methods.  Small,  nodular  epitheliomas, 
situated  on  the  surface  of  the  skin,  can  often  be  readily  de- 


DERMATOLOGICAL  CONGRESS  509 

stroyed  by  a  few  applications  of  the  high-frequency  spark. 
The  modus  operandi  is  to  use  a  spark  strong  enough  to  destroy 
the  lesion  and  then  to  wait  until  the  scab  formed  has  fallen  off 
— probably  two  or  three  weeks — and  to  repeat  the  operation 
if  necessary.  The  best  electrode  for  this  purpose  is  the  one 
first  suggested  to  me  by  Dr.  Lustgarten,  consisting  of  an 
ordinary  lead  pencil  sharpened  on  both  ends,  with  a  piece  of 
lead  foil  around  one  end  fitted  into  a  handle. 

Large  unindurated  epitheliomas  are  best  treated  with 
the  X-ray.  In  large  epitheliomas  with  indurated  borders, 
we  have  found  most  satisfaction  in  destroying  the  borders 
with  the  high-frequency  spark,  and  then  treating  them  with 
the  X-ray.  This  combination  of  the  two  methods  is  pro- 
bably the  one  we  most  resort  to.  We  often  find  that  epi- 
theliomas will  improve  up  to  a  certain  point  under  X-ray 
treatment,  and  then  come  to  a  standstill,  when  probably  a 
few  applications  of  the  high-frequency  spark  will  bring  about 
a  cure. 

We  have  treated  eighty-five  cases  of  epithelioma  by  these 
methods.  Out  of  these,  forty-five  were  clinically  cured ;  one 
was  referred  for  other  treatment ;  some  deserted  before  treatment 
had  a  fair  chance;  others  were  lost  track  of.  It  is  extremely 
difficult  to  keep  in  touch  for  any  length  of  time  with  patients 
treated  in  an  out-door  patient  department  of  a  hospital. 

Carcinoma.  We  have  had  a  large  number  of  deep-seated 
recurrent  carcinomas  referred  to  us  for  X-ray  treatment,  but 
as  these  are  not  dermatological  cases  proper,  I  will  not  dwell 
upon  them,  simply  stating  that  we  have  often  had  encouraging 
results  for  a  while,  only  to  be  disappointed  in  the  end.  Per- 
sonally, I  have  never  seen  a  deep-seated  internal  carcinoma 
cured  with  the  X-ray. 

Sarcoma.  The  results  accomplished  in  various  types  of 
sarcoma  are  somewhat  more  encouraging.  Occasionally  we 
get  startling  results.  The  following  case  is  one  of  the  most 
interesting:  A.  R.,  female,  aged  21.  Was  referred  to  the 
clinic  on  August  i,  1906,  by  the  surgical  division,  with  the 
following  history.  Three  years  ago  she  had  sarcoma  of  the 
right  scapula,  which  was  removed  by  Dr.  Lilienthal.  About 
five  months  ago  she  noticed  a  swelling  behind  the  right  ear, 


Sio  SIXTH  INTERNATIONAL 

which  began  to  increase  rapidly  until  when  operated  upon 
on  July  15,  1906,  it  was  the  size  of  a  hen's  egg.  Operation 
was  performed  by  Dr.  Elsberg,  who  found  the  growth  in- 
operable. A  small  section  was  removed  for  pathological 
examination,  and  the  diagnosis  of  "  metastatic  perforating 
sarcoma  of  the  dura"  was  established.  X-ray  treatment 
was  begun  September  igth.  After  sixteen  treatments  her 
condition  was  very  much  improved.  The  pain  had  entirely 
disappeared  and  there  was  hardly  any  sign  of  the  tumor  left. 
Treatment  was  discontinued  for  a  while.  On  October  8th 
treatment  was  begun  again ;  between  that  date  and  November 
1 9th  she  had  twelve  additional  X-ray  exposures,  with  the 
astonishing  result  of  the  complete  disappearance  of  the  tumor. 
Unfortunately,  somewhat  later,  she  developed  metastases 
in  the  lungs,  which  rapidly  proved  fatal. 

In  two  cases  of  sarcoma  haemorrhagicum  and  two  cases 
of  sarcomatosis  cutis  pigmentosa  there  was  a  very  decided 
improvement  under  treatment  with  the  X-ray. 

Acne  Vulgaris.  These  cases  make  up  a  large  part  of 
dermatological  practice,  and  the  results  accomplished  with 
them  by  the  aid  of  the  X-ray  are  extremely  gratifying. 

It  is  preferable  to  puncture  and  evacuate  the  pustules 
and  then  to  apply  the  X-ray.  The  average  duration  of 
treatment  necessary  is  from  four  to  six  weeks.  The  number 
of  exposures  required  is  about  a  dozen,  and  they  might  be 
given  at  the  rate  of  about  two  or  three  a  week  at  first,  and 
later  one  a  week.  Treatment  might  be  continued  until  there 
is  a  very  slight  dermatitis,  when  it  must  be  promptly  dis- 
continued— but  it  is  only  rarely  that  we  continue  the  treat- 
ment to  the  development  of  even  a  mild  dermatitis.  As  a 
rule,  the  improvement  begins  after  a  few  treatments. 

We  have  treated  about  one  hundred  and  twenty  of  these 
cases  with  generally  good  results. 

Acne  Rosacea.  The  results  accomplished  in  this  form 
of  disease  are  not  very  satisfactory.  Other  methods  of 
treatment  are  preferable.  In  fifteen  cases  treated  there  was 
very  little  accomplished. 

Psoriasis.  The  value  of  the  X-ray  in  psoriasis  is  well 
established. 


DERMATOLOGICAL  CONGRESS  511 

The  length  of  treatment  necessary  to  cure  it  depends  very 
much  upon  the  nature  of  the  lesions.  Acute  and  subacute 
lesions — that  is,  those  that  do  not  have  much  induration  and 
are  covered  with  small  flake-like  scales — yield  much  quicker 
to  treatment  than  the  old  chronic  indurated  spots  covered 
with  thick  scales.  Those  situated  on  the  face  and  scalp 
generally  yield  quicker  than  those  on  the  trunk  and  ex- 
tremities. As  a  rule,  we  do  not  treat  psoriasis  situated  on 
the  trunk  with  X-ray,  on  account  of  the  possible  injury  to  the 
underlying  viscera.  The  treatment  does  not  seem  to  have 
had  much  influence  upon  the  recurrence  of  the  lesion,  although 
it  seems  to  me  as  if  those  cases  where  the  X-ray  has  been 
used  until  a  dermatitis  and  peeling  off  of  the  skin  have  been 
produced  remain  free  for  a  longer  period  than  those  cured 
by  other  methods. 

The  number  of  patients  treated  was  forty-eight. 

Eczema.  The  results  accomplished  in  this  class  of  cases 
is  very  encouraging.  Eczemas  of  all  varieties  yield  more  or 
less  readily  to  the  X-ray. 

The  moist,  weeping  kind  generally  requires  less  treatment 
than  the  dry,  scaly  patches.  I  have  repeatedly  seen  cases 
of  years'  standing,  that  have  resisted  every  other  form  of 
treatment,  cured  with  the  X-ray.  We  have  treated  one  hun- 
dred and  twenty-five  cases  with  generally  good  results  in  all 
those  who  have  sufficiently  persisted  with  the  treatment. 

In  lichen  chronicus,  lichen  planus,  and  lichenoid  eczema 
conditions,  while  the  subjective  symptoms  yield  readily  to 
treatment,  as  a  rule  they  are  more  stubborn  as  to  final  results 
than  the  cases  of  eczema. 

Out  of  forty-five  cases  treated,  the  large  majority  were 
cured. 

Lupus  Erythematosus.  At  one  time  it  looked  very  much 
as  if  the  high-frequency  spark  was  the  ideal  treatment  for 
lupus  erythematosus,  especially  if  the  lesion  was  not  an  ex- 
tensive one.  As  a  rule,  the  results  were  very  prompt;  we 
could  destroy  a  small  area  at  each  treatment,  with  a  remaining 
smooth,  flat  scar. 

The  method  used  is  that  of  holding  the  pencil  electrode 
within  a  very  short  distance  (about  2  mm.)  of  the  lesion,  with 


Si2  SIXTH  INTERNATIONAL 

a  current  of  sufficient  intensity  to  destroy  the  tissue  to  the 
depth  desired.  In  using  the  high-frequency  spark  as  a  de- 
structive agent,  the  most  important  thing  is  the  regulation 
of  the  spark-gap.  It  is  advisable  to  have  an  indicator  on  the 
rod,  with  which  the  spark-gap  is  regulated,  which  shows  at  a 
glance  the  length  of  the  spark  with  which  we  are  working.  As 
a  rule  a  short  spark  is  sufficient. 

For  superficial  destruction,  a  pointed  glass  vacuum  elec- 
trode will  suffice,  but  where  deeper  destruction  is  required 
we  must  use  carbon  or  metallic  electrodes.  The  determina- 
tion as  to  the  proper  amount  of  destruction  required  can  only 
be  gained  by  personal  experience.  Unfortunately,  in  lupus 
erythematosus  the  treatment  does  not  guard  against  re- 
currence, and  I  regret  to  state  that  while  the  immediate 
result  is  good,  the  ultimate  result  is  not  quite  so  favorable. 

We  have  treated  forty  cases  with  good  immediate  result, 
but  with  recurrence  in  a  large  number  of  them. 

Lupus  Vulgaris.  We  do  not  see  very  many  of  these  cases 
in  our  clinics  in  this  country. 

Lupus  of  the  mucous  membranes  is  best  treated  with  the 
X-ray,  while  lupus  of  the  other  parts  of  the  skin  seems  to 
yield  quicker  to  the  sparking,  as  above  mentioned. 

In  six  cases  treated,  there  were  cures  in  three,  and  im- 
provement in  the  others. 

Five  cases  of  tuberculosis  verrucosa  cutis  did  very  well  with 
the  high-frequency  spark  treatment. 

In  common  alopecia,  if  it  has  not  progressed  too  far,  and 
if  it  is  the  result  of  an  insufficiency  of  blood  supply  to  the  scalp, 
a  great  deal  can  be  accomplished  with  the  high-frequency  flat 
vacuum  electrode-labile  applications,  using  the  current  strong 
enough  to  produce  a  fair  degree  of  hyperaemia  of  the  scalp. 

In  alopecia  areata,  the  result  is  about  the  same  as  that 
accomplished  by  other  methods. 

We  have  treated  thirty-five  cases  of  alopecia. 

The  high-frequency  spark  is  of  very  great  value  in  the 
destruction  of  verrucas  of  different  types ;  also  in  the  destruction 
of  different  forms  of  n&vi,  and  in  molluscum  contagiosum.  In 
small,  superficial  lesions,  the  pointed  glass  electrode  is  to  be 
preferred,  on  account  of  its  being  less  painful  and  producing 


DERMATOLOGICAL  CONGRESS  513 

practically  no  scarring  whatever;  but  in  larger  lesions,  where 
deeper  destruction  is  required,  we  must  use  the  carbon  elec- 
trodes. In  a  bad  case  of  ncevus  pigmentosus  pilosus,  situated 
on  the  face  of  a  young  girl,  I  applied  the  X-ray  until  it  pro- 
duced a  second  degree  dermatitis  which  healed  rapidly,  leav- 
ing a  very  good  scar.  I  think  this  is  a  very  good  way  of 
treating  these  cases,  but  we  must  be  careful  not  to  produce 
too  serious  a  dermatitis. 

In  all,  we  treated  seventy-five  of  these  cases. 

Keloid.  The  X-ray  has  a  very  decided  action  on  scar 
tissue.  It  does  not  require  many  treatments  to  produce 
a  more  or  less  flattening  of  keloidal  growths,  but  to  expect  a 
permanent  cure  it  appears  to  be  necessary  to  continue  the 
treatment  until  we  have  produced  a  fair  degree  of  dermatitis. 

There  were  fifteen  of  these  cases  treated. 

In  four  cases  of  folliculitis  decalvans  treated  with  the 
X-ray,  the  result  was  very  satisfactory. 

In  pruritus,  due  to  various  causes,  the  X-ray  and  high- 
frequency  currents  both  seem  to  have  the  property  of  allay- 
ing itching.  In  treating  young  persons,  especially  if  the 
pruritus  is  in  the  genital  region,  we  must  keep  in  mind  the 
property  of  the  X-ray  to  produce  sterility,  and  depend  upon 
the  high-frequency  efHuvae,  which  is  harmless. 

We  treated  twenty-eight  of  these  cases. 

In  a  case  of  kraurosis  vulvas,  in  an  old  lady  of  76,  after 
a  half  dozen  X-ray  exposures  up  to  date,  there  is  very  little 
improvement. 

Mycosis  Fungoides.  This  is  one  of  the  conditions  in  which 
we  were  absolutely  helpless  until  the  X-ray  era  began.  At 
present  we  can  do  a  great  deal  for  it  with  the  X-ray,  but  I 
am  sorry  to  say  the  lesions  are  only  controlled,  not  permanently 
cured.  We  treated  five  of  these  cases,  and  all  have  been 
repeatedly  clinically  cured,  only  to  relapse  shortly  after 
treatment  was  discontinued.  One  case  has  been  under 
treatment  for  the  past  three  years,  and  is  apparently  well  as 
long  as  he  gets  his  weekly  exposures,  but  returns  with  new 
patches  if  treatment  is  discontinued  for  a  while.  The  sub- 
jective symptoms,  the  very  bad  itching,  are  generally  im- 
proved in  a  short  time,  and  the  patients  continue  in  their 

VOL.   I — 33 


5i4  SIXTH  INTERNATIONAL 

regular  occupations  with  a  feeling  of  general  well-being.  This 
in  itself  is  a  great  triumph  for  the  X-ray. 

Rhinoscleroma.  Probably  the  most  gratifying  results  in 
the  field  of  radiotherapy  are  accomplished  in  this — up  to  a 
short  time  ago  regarded  as  incurable — ailment.  One  of  the 
most  interesting  cases  was  that  of  a  woman,  Russian  by  birth, 
53  years  old,  who  was  referred  to  the  clinic  for  treatment  by 
Dr.  Milton  J.  Ballin,  on  June  i,  1906.  The  history  dates  back 
sixteen  years  when  the  nose  first  began  to  enlarge  and  the 
pharynx  and  naso-pharynx  became  involved.  In  these  latter 
organs,  the  condition,  which  began  in  a  catarrhal  form,  pro- 
ceeded to  a  process  of  ulceration  which  gradually  healed, 
leaving  a  firm  cicatricial  band.  The  nose  continued  to  en- 
large, despite  all  treatment;  several  operations  performed 
had  no  effect  whatever.  When  she  presented  herself  for 
treatment  the  nose  was  probably  double  its  natural  size,  with 
a  large  ulcerating  growth  spreading  from  both  nostrils  over 
the  upper  lip.  The  nasal  passages  were  entirely  occluded, 
the  whole  organ  having  a  hard,  ivory  consistency. 

The  treatment  was  at  first  given  three  times  a  week  with 
a  medium  vacuum  tube,  at  a  distance  of  about  four  inches,  for 
a  period  of  five  minutes.  As  the  extra-nasal  part  of  the 
growth  disappeared,  a  tube  of  a  higher  degree  of  vacuum  was 
used,  and  the  exposures  reduced  to  twice  a  week.  She  de- 
veloped a  mild  degree  of  dermatitis  several  times,  which 
promptly  disappeared  on  discontinuing  treatment  for  a  week 
or  two.  The  improvement  was  very  rapid.  It  began  after 
the  first  few  treatments,  and  at  the  end  of  five  months  the  nose 
looked  practically  normal.  In  another  case  of  rhinoscleroma 
which  has  only  been  under  treatment  for  a  short  time  there 
is  also  a  decided  improvement. 

We  also  treated  at  the  hospital  a  most  interesting  case  of 
primary  scleroma  of  the  larynx,  due  to  the  bacillus  of  rhino- 
scleroma.  This  was  in  a  young  woman  of  21,  born  in  Russia, 
who  came  to  the  clinic  of  Dr.  Emil  Mayer  with  symptoms 
of  hoarseness  and  dyspnoea.  On  examination  a  large  growth 
was  seen  under  the  vocal  cords  on  a  level  with  the  cricoid 
cartilage,  almost  entirely  occluding  the  calibre  of  the  larynx. 
A  small  section  was  removed  and  the  pathological  examination 


DERMATOLOGICAL  CONGRESS  515 

proved  it  to  be  rhinoscleroma.  She  was  referred  for  X-ray 
treatment,  but  after  only  one  or  two  exposures  the  dyspnoea 
became  so  marked  that  it  was  decided  to  open  up  the  larynx. 
This  was  done  by  Dr.  Gerster  on  March  30,  1907,  who  made 
a  longitudinal  incision  three  and  one-half  inches  long,  reaching 
to  within  one-quarter  of  an  inch  of  the  sternum.  A  trache- 
otomy tube  was  inserted,  and  the  rest  of  the  incision  was 
kept  open  to  allow  more  direct  application  of  the  X-ray.  The 
first  application  was  given  on  April  pth,  under  an  anaesthetic, 
with  the  walls  of  the  larynx  held  open  by  retractors.  The 
subsequent  applications  were  given  without  an  anaesthetic, 
at  the  rate  of  three  times  a  week,  each  of  five  minutes'  duration 
and  applied  through  a  Friedlander  shield,  with  the  opening 
of  the  hard-rubber  attachments  in  direct  contact  with  the  in- 
cision. The  tumor  yielded  rapidly  to  this  treatment.  On 
May  i $th,  five  weeks  after  treatment  was  begun,  the  tracheo- 
tomy tube  was  removed  and  the  incision  permitted  to  heal 
by  granulation.  An  examination  of  the  larynx  at  this  time 
showed  it  to  be  perfectly  clear,  and  no  signs  of  any  remains 
of  the  tumor  could  be  seen.  The  dyspnoea  had  entirely  disap- 
peared, and  the  patient's  condition  was  very  good.  A  laryn- 
gological  examination  made  five  months  later  shows  the 
larynx  to  be  entirely  clear  and  no  signs  of  any  recurrence 
whatever. 

Sycosis.  This  is  one  of  the  conditions  in  which  the  opinion 
of  all  dermatologists  as  to  the  value  of  the  X-ray  is  practically 
unanimous. 

The  results  accomplished,  in  comparison  with  other  meth- 
ods of  treatment,  are  simply  marvellous.  I  have  repeatedly 
seen  cases  of  five  years'  standing,  involving  almost  all  the 
hair  follicles  of  the  face,  cured  in  six  weeks'  treatment.  The 
method  of  treatment  is  to  continue  with  the  X-ray  until  all 
the  affected  hairs  are  epilated. 

We  have  treated  one  hundred  and  five  of  these  cases,  with 
almost  one  hundred  per  cent,  cures. 

The  action  of  the  X-ray  upon  the  hair  follicles  in  pro- 
ducing epilation  can  be  well  utilized  in  other  diseases  affect- 
ing the  hairy  portions  of  the  body — such  as  trichophytosis  capitis, 
of  which  we  have  treated  thirty  cases  with  fairly  good  results. 


5i6  SIXTH  INTERNATIONAL 

Also  in  favus,  of  which  there  were  five  cases  treated  with 
good  results. 

In  these  latter  two  conditions  it  is  advisable  to  apply 
various  germicidal  ointments  in  addition  to  the  X-ray. 

Another  condition  in  which  the  epilating  power  of  the 
X-ray  can  be  made  of  great  value  is  in  hypertrichosis.  Hair 
epilated  with  the  X-ray,  if  left  alone,  generally  returns  in 
about  two  or  three  months,  but  if  an  occasional  exposure  is 
given  for  a  long  time,  probably  a  year  after  epilation,  the  hair 
follicles  become  permanently  destroyed. 

This  condition  requires  the  most  careful  technique,  for 
we  must  keep  in  mind  that  the  treatment  is  for  cosmetic 
reasons,  and  to  replace  superfluous  hairs  with  a  bad  X-ray 
burn  which  will  probably  leave  behind  a  permanent  network 
of  telangiectatic  blood  vessels  may  lead  to  serious  inconvenience. 
We  do  not  treat  these  patients  in  the  clinic,  but  in  private 
practice  I  have  treated  fifteen  cases  with  good  results  in 
those  who  had  sufficient  perseverance. 

I  might  also  mention  several  cases  of  hyperidrosis,  affecting 
the  palms  of  the  hands,  who  improved  under  X-ray  treatment, 
but  only  after  a  long  series  of  treatments.  In  a  patient  with 
xanthoma  diabeticorum,  who  had  cord-like  ridges  over  both 
palms,  arms,  and  legs,  there  was  a  decided  flattening,  and 
even  complete  disappearance  of  the  ridges  on  the  parts  treated. 

Discussion 

DR.  M.  B.  HARTZELL,  of  Philadelphia,  said  there  were  one  or 
two  points  in  connection  with  the  X-rays  that  he  wished  to  speak 
about,  and  one  was,  the  use  of  this  agent  in  the  treatment  of 
epitheliomata  occurring  at  the  muco-cutaneous  borders.  The 
dermatologists  had  been  treated  rather  badly  by  the  surgeons  in 
this  connection.  They  had  been  told  repeatedly  that  the  man 
who  treated  an  epithelioma  of  the  lower  lip  with  the  X-rays  instead 
of  having  it  excised  was  pursuing  a  course  that  was  little  short 
of  criminal.  In  spite  of  that  fact  we  knew  there  were  certain 
cases  where  the  X-ray  might  be  employed  with  the  utmost  pro- 
priety. The  speaker  referred  to  two  such  instances  coming  under 
his  observation.  One  was  a  typical  epithelioma  of  the  lower  lip  in 
a  patient,  ninety-four  years  old,  who  had  refused  radical  treatment 
by  the  knife.  After  ten  three-minute  exposures  with  the  X-ray  the 


DERMATOLOGICAL  CONGRESS  517 

lesion  disappeared,  and  the  man  had  thus  far  remained  well.  He 
had  avoided  what  he  regarded  as  a  very  serious  operation. 

In  the  second  case  there  were  two  fungating  lesions  of  the 
lower  lip  in  a  man  who  refused  operation.  These  were  also  cured 
under  X-ray  treatment.  Dr.  Hartzell  said  he  was  willing  to  admit 
that  the  proper  treatment  of  epithelioma  of  the  lower  lip  was  ex- 
cision, with  removal  of  the  adjacent  glands,  but  there  were  certain 
cases  in  which  resort  to  the  X-rays  was  entirely  proper  and  some- 
times necessary. 

As  to  the  treatment  of  acne,  the  speaker  said  he  believed  the 
X-ray  treatment  should  be  reserved  for  the  cases  which  failed  to 
improve  under  other  methods.  We  were  beginning  to  learn  that 
the  application  of  the  X-rays  to  the  face  was  apt  to  be  followed 
by  an  atrophy  of  the  skin,  which  was  very  disfiguring.  For  that 
reason  the  treatment  should  not  be  resorted  to  in  acne  excepting 
where  other  remedies  had  failed. 

DR.  BURNSIDE  FOSTER,  of  St.  Paul,  said  that  after  a  fair  ex- 
perience with  the  use  of  the  X-rays  he  was  able  to  confirm  the 
favorable  results  that  had  been  reported  by  the  various  speakers. 
The  dangers  of  the  X-rays  in  the  hands  of  the  expert  were  not  to 
be  despised,  and  in  the  hands  of  the  novice  were  great.  The 
speaker  said  he  had  seen  deplorable  results  follow  the  treatment 
in  cases  of  psoriasis,  eczema,  favus,  and  ringworm,  and  they  were 
largely  due  to  the  method  in  which  the  treatment  was  applied 
by  inexperienced  operators.  This  fact  could  not  be  too  strongly 
emphasized,  especially  in  view  of  the  fact  that  the  apparent  sim- 
plicity of  the  method  appealed  to  every  one.  For  that  reason 
many  men  were  apt  to  take  up  the  treatment  and  apply  it  indis- 
criminately who  were  entirely  unfitted  for  it.  As  a  result,  their 
patients  grew  worse,  and  the  physicians  laid  themselves  open 
to  damage  suits,  and  he  had  one  case  of  the  kind  in 
mind  where  a  verdict  in  favor  of  the  patient  would  probably 
be  rendered.  He  suggested  that  the  Congress  should  put 
itself  on  record  in  regard  to  the  dangers  of  the  X-rays  in 
inexperienced  hands. 

DR.  FRANCIS  J.  SHEPHERD,  of  Montreal,  said  he  was  very  much 
interested  in  the  cases  detailed  by  Dr.  Pusey,  whose  results  with 
the  X-ray  treatment  were  in  some  respects  quite  wonderful.  In 
certain  cases  of  epithelioma,  notably  in  lesions  about  the  eyelids, 
the  X-ray  was  probably  the  best  method  of  treatment,  but  when 
it  came  to  lesions  of  the  lower  lip  and  of  the  muco-cutaneous  sur- 


Si8  SIXTH  INTERNATIONAL 

faces,  the  speaker  said  he  would  strongly  object  to  the  use  of  the 
rays,  especially  where  there  was  a  liability  to  early  involvement 
of  the  glands.  Under  such  conditions  surgical  treatment  was 
strongly  indicated. 

Dr.  Shepherd  asked  how  one  could  select  the  proper  cases  for 
X-ray  treatment?  How  could  one  tell  whether  the  glands  were 
involved  or  not?  The  same  rule  applied  here  as  in  Paget's  disease 
of  the  nipple,  and  in  dealing  with  epithelioma  of  the  lower  lip, 
one  should  not  waste  time  with  the  X-rays.  To  do  so  was  to 
subject  the  patient  to  unnecessary  risk. 

DR.  WILLIAM  A.  PUSEY,  of  Chicago,  said  the  question  of  whether 
a  case  was  suitable  or  not  for  treatment  with  the  X-rays  had  been 
brought  up  several  times.  In  his  opinion,  there  was  no  reason 
for  trying  to  select  a  peculiar  type  of  epithelioma  to  be  treated 
with  X-rays.  He  had  a  rule  of  his  own,  which  he  had  found  both 
safe  and  defensible.  He  was  willing  to  treat  any  epithelioma  with 
X-rays  in  which  a  conservative  surgeon  did  not  consider  it  feasi- 
ble or  necessary  to  remove  the  contiguous  glands.  That  at  once 
eliminated  most  cases  of  epithelioma  about  the  muco-cutaneous 
junction  where  operation  was  possible.  It  did  not  eliminate 
those  in  very  old  people,  or  those  rare  cases  where  an  operation 
would  not  be  tolerated.  Subject  to  this  limit  he  believed  X-rays 
need  not  be  restricted  to  any  particular  field.  If  it  was  not 
as  reliable  in  one  lesion  as  in  another,  it  was  not  worth  while  con- 
sidering. Dr.  Pusey  said  he  had  never  seen  a  mass  of  carcinoma 
involving  the  skin  that  did  not  ultimately  undergo  degeneration 
under  the  influence  of  X-rays.  He  recalled  one  case  of  enormous 
epithelioma  involving  the  glabella  in  which  X-ray  treatment  was 
continued  for  over  three  months  without  getting  any  reaction. 
After  making  an  ineffectual  attempt  to  have  the  case  treated 
surgically,  he  again  resorted  to  X-rays  in  enormous  quantities. 
This  time  the  treatment  was  followed  by  a  reaction  and  degenera- 
tion, and  the  lesion  was  reduced  to  a  flat  ulcer  which  promptly 
healed.  The  question  of  resistance  of  epitheliomas  to  X-rays 
was  largely  one  of  personal  equation  of  the  patient  and  he  did  not 
believe  that  there  was  any  epithelioma  that  could  not  be  made  to 
degenerate  under  X-rays.  It  seemed  to  him  that  with  both  X-rays 
and  radium  we  were  dealing  with  practically  the  same  agent,  and 
that  under  the  influence  of  these  rays  there  was  an  absorption 
of  energy  by  the  cells  which  eventually  caused  them  to  disinte- 
grate. It  was  purely  a  cellular  disintegration  caused  by  the  fact 


DERMATOLOGICAL  CONGRESS  519 

that  tissue  cells  are  susceptible  to  this  form  of  energy,  just  as 
silver  salts  are. 

PROF.  E.  GAUCHER,  de  Paris,  a  dit:  Au  risque  de  passer  pour 
un  re"actionaire,  qu'il  voudrait  re"frener  un  peu  1'enthousiasme  des 
partisans  des  rayons  X  et  du  radium.  Dans  la  majorite*  des  cas, 
pour  les  e'pitheliomas  superficiels  et  de  petite  dimension,  on  arri- 
vait  a  un  r^sultat  satisfaisant  beaucoup  plus  rapide  et  beaucoup 
moins  couteux  en  de*truisant  la  lesion  par  carbonisation  a  1'aide 
du  thermo-cauteYe.  Pour  les  e'pithe'liomas  tres  e"tendus,  il  croyait 
qu'il  e*tait  prudent  de  ne  pas  trop  attendre  pour  pratiquer  1 'exercise 
et  perdre  son  temps  en  employant  la  radiothe"rapie.  Apr£s  avoir 
employe"  beaucoup  la  radiothdrapie,  il  pensait  qu'elle  ne  pre*sentait, 
dans  la  majorite"  des  cas,  aucun  avantage  marque*  sur  les  an- 
ciennes  me'thodes,  sans  parler  des  accidents  de  radiodermite  plus 
ou  moins  graves,  auxquels  elle  pouvait  exposer. 

PROF.  THEODOR  VEIEL,  of  Cannstatt,  Wurttemberg,  said  that 
Prof.  Gaucher's  remarks  were  similar  to  those  of  his  own  which 
he  had  made  at  the  International  Congress  in  Berlin.  At  that 
time  he  had  expressed  the  view  that  the  X-ray  therapists  were 
going  too  far,  and  should  leave  more  to  the  surgeon.  He  could 
recall  many  cases  that  were  kept  too  long  in  the  hands  of  the 
radio-therapist  and  came  too  late  to  the  surgeon.  It  was  better 
not  to  attempt  too  much  with  the  X-rays,  especially  in  cases 
where  there  was  infiltration,  or  where  the  glands  were  involved. 

DR.  HERMAN  LAWRENCE,  of  Melbourne,  Australia,  said  he  did 
not  expect  the  X-ray  baths  described  in  his  paper  to  be  used  by 
any  one  who  had  not  the  proper  experience  with  this  agent.  Other- 
wise the  treatment  might  lead  to  even  fatal  results.  Personally, 
he  had  treated  many  cases  of  acne  vulgaris  with  mild  doses  of  the 
X-ray  and  had  never  observed  any  bad  results. 

DR.  SAMUEL  STERN,  of  New  York  City,  said  that  in  connection 
with  the  treatment  of  epitheliomata  of  the  eyelid  by  means  of 
radium,  to  which  two  of  the  speakers  had  referred,  he  wished  to 
call  attention  to  a  case  of  this  kind  which  he  had  exhibited  at 
the  Clinical  Session  of  the  Congress  on  Tuesday  morning.  In  that 
case  radium  had  been  tried  for  five  months  without  any  result  and 
was  promptly  cured  with  the  X-rays.  This  was  perhaps  an 
exception  to  the  rule,  but  the  result  spoke  for  itself. 


520         SIXTH  INTERNAT.  DERMATOL.  CONGRESS 

Dr.  Stern  said  he  was  glad  to  hear  Dr.  Pusey's  statement  in 
regard  to  the  effect  of  the  X-rays  on  epitheliomata.  He  agreed 
with  him  with  the  exception  that  he  found  that  in  dealing  with 
deeper-seated  hard  nodular  epitheliomata  or  with  the  thick  hard- 
ened keratotic  form  known  as  "seafarer's  epithelioma"  it  would 
take  a  long  time  to  produce  a  reaction  with  the  X-ray,  and  other 
methods  of  treatment  were  preferable. 

Adjournment  at  i  p.m. 


3  1 158  00821  «'" 


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